Columbia  Hmfrrorttj) 

(EoUwjf  of  PijjHiriattfi  auii  ^urgraufi 


Ifcfrmtr?  IGtbranj 


ANOCI  -ASSOCIATION 


GEORGE  W.  CRILE,  M.D. 

R  OF  51  RC1  RY,  S(  HOOl    OF  MEDICINE,  WESTERN  KESEK\  I    UNIVERSITY 
VISITING  SURGEON  TO   I  Hi    I  AM  MM    HOSPITAL,  CLEVE1   INO 


WILLIAM  E.  LOWER,  M.D. 

ASSOCIATE    PROFESSOR   OP   GBNITO-URINARY    51  l:<.lK\.    51  I I     MEDICINE, 

WEST!  I     I  •■!■■  i  i     i  I  I  :     ASSOCIATE  SURGEON  TO  TH1 

I  AKBSID1     HOSPI  I  AI  .  i  ll  VI  I  AND 


I  III  I  I  D    BY 

AMY    F.    ROW  LAM) 


ORIC.IS.II    II 1 1  STRATION& 


I'llll  \DI  l  PHI  \    \M)  I  ONDON 

\\ .  B.  SAT  NDERS  COMPANY 
L915 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/anociassociationOOcril 


CONTEXTS 
Introduction 

Bt  <  ii  OHQi    w  .  Crile,  m.  d. 

PAGE 

Tlie  Evolution  of  the  Kinetic  Theory  of  Shuck  and  the  Shock- 
less  Operation 19 

Part  I 
The  Kinetic  Theory  of  Shock  and  Anoci-association 

By   < ...i     \\  .  (   1:11.1  ,  M.  I). 

Chapter  I.  The  Kinetic  Theory  of  Shock 29 

The  Kinetic  Theory  of  Shock     General  Statemen I     '_".• 

Chapter  II.  The  Histologic  Pat holony  of  Shock ill 

Traumal  ic  Shock 19 

Emot  ional  Shock 56 

Toxic,  Foreign  Proteid  and  Anaphylactic  Shock .  .  56 

Drugs     Anesthetics,  Narcotics,  and  Stimulants.  67 

Alleluia 68 

Are  the  Cell-changes  Seen  in  Shock  Due  to  the 
I'nxl  i  icis  of  Pathologic  Metabolism  or  to  Altered 
Gases  in  the  Blood '■'• 

The  Influence  of  the  Inhalation  Anesthetics  upon 
Shock-production 77 

Chapter        111.  The  Clinical  Pathology  of  Shock 80 

Shock-producing  Effect  of  Stimulation  of  Contact 

<  'eplols     80 

<  lomparat  >\  e  Shock-producing  Effects  of  Traumata 

of  Different  Parte  of  'lie  Bodj  81 

Comparative  si k-producing  Effects  of  Different 

Types  of  Trauma  vl' 
Specificity  of  Nerve-muscular  Response  to    Ade- 
quate St  lllllll.lt  loll    ss 

SI k-producing    Effect    of    Stimulation    of    the 

I  distance   <  leptors     The    I  Imot  ion       I       cially 
I  eat 

Chapter        IV.  The  Kinetic  Theory  of  Shock    Summary  ..    inn 

9 


10  CONTENTS 


Part  II 

The   Treatment   of   Shock   and    its   Prevention   through    Anoci- 

association 

By  George  W.  Crile,  M.  D.,  and  William  E.  Lower,  M.  D. 

page 

Chapter  V.  The  Treatment  of  Shock 105 

Chapter         VI.  Anoci-association 108 

Principle 108 

General  Technique 113 

Morphin  and  Scopolamin   113 

Nitrous-oxid-oxygen 116 

Novocain 117 

Quinin  and  Urea  Hydrochlorid 119 

Gentle  Manipulations;  Sharp  Dissection 120 

Chapter       VII.  Anoci-association  in  Abdominal  Operations  122 

Biologic  Considerations 122 

General  Technique 126 

Chapter     VIII.  Anoci-association  in  Abdominal  Operations — 

Continued 132 

Operations  on  the  Gall-Bladder 132 

Common  Duct  Operations 134 

Operations  in  the  Stomach 138 

1  Resection  of  the  Intestines 140 

Herniotomy 142 

Perineal  Operations 144 

Rectal  Operations 144 

Chapter        IX.  Anoci-association  in  Abdominal  Operations — 

Continued 146 

Acute  Abdominal  Infections 146 

Acute  Appendicitis 147 

Acute  Infections  of  the  Upper  Abdomen 151 

Pelvic  Infections 152 

Summary 152 

Chapter         X.    Anoci-association  in  Gynecologic  Operations  153 

Benign  Tumors 153 

Pus  Tubes 156 

Suspension  of  the  Uterus 157 

Chapter        XI.  Anoci-association  in  Genito-urinary  Opera- 
tions     158 

Bladder 158 

Prostate 158 

Kidney 160 


CONTENTS  11 

PAGE 

Chapter      XII.  Two-stage  Operations 173 

Cancer  of  the  Rectum 171 

<  ancer  of  the  Stomach 171 

( !ancer  of  the  Uterus 17." 

( !ancer  of  t  he  Larynx L79 

( lancer  of  the  Tontine l  vi 

Summary L89 

Chapter  XIII.  Anoci-association  in  Treatment  of  Exoph- 
thalmic <  roiter 190 

Chapter     XIV.  Anoci-association  in  Operations  on  the  Brain  199 

Chapter       XV.  Anoci-association  in  Operations  for  Cancer 

of  the  Breasl 201 

Chapter  XVI.  Anoci-association  in  operation-  on  the  Ex- 
tremities   Accidents 203 

Amputations 203 

I  Osteotomy 204 

( leneral  <  !onsidera1  ions  in  Accident  Cases  204 

Chapter  XVII.  The  [mportance  ol  Anoci-association  to 
Patients  Handicapped  by  too  High  or  too 
Low  Blood-pressure 206 

Hypertension    206 

Hypotension 210 

Chapter  XVIII.  The  Relation  of  Anoci-association  to  Post- 
operative Morbidity  and  Mortality  212 

I  i:i-  Pain 213 

Painful  Scar  21  I 
Nervousness  216 
Aseptic  Wound   Fever  and   Postoperative  Hyper- 
thyroidism    217 

Nausea  and  Vomiting     Digestive  Disturbances  218 

Backache  219 

[nfection.  219 

Nephritis  219 

Pneumonia  \l\l<) 
Mortality 

( lhapter     XIX.  Summary .  223 

Appendix 
The  Technique  of  Administering  Nitrous-Oxid-Oxygen  Anesthesia 

B\         \  •  •  \   I  1 1  \       II"! 

Preliminary .  226 

Induction  of  Inesl  I 
[nducl  ion  of    Ancsl  hesia     Second  Si 
The  Maintenance  of   Anesthesia  during  Operation  231 
Position  of  the  Patienl  during  Anesthesia 


12  CONTENTS 

PAGE 

Technique  for  Special  Operations 240 

Exophthalmic  Goiter 240 

Surgical  Shock  and  Collapse 242 

Face,  Mouth  and  Neck  Operations 242 

Laryngectomy 242 

Brain  Operations 243 

Tonsils  and  Adenoids 243 

Acute  Infections 243 

Operations  on  the  Thorax 243 

Analgesia 244 

Summary 245 

Anoci-association  in  its  Relation  to  the  Preoperative  and  Post- 
operative Care  of  Patients. 

By  Samuel  L.  Ledbetteb,  Jr.,  M.  D. 

Preoperative  Case 246 

Postoperative  Management  of  Cases  in  General.  .  247 

Sedatives 248 

Nourishment 248 

Stimulation 248 

Preoperative  and   Postoperative  Care  in  Special 

Cases 249 

A  Hospital  Plant  for  the  Manufacture  of  Nitrous  Oxid 252 

By  A.  R.  Warner,  M.  D. 


Index 255 


J. 1ST  OF  ILLUSTRATIONS 

Fig.  page 

1.  Brain-cells  showing  stage  of  hyperchromatism  followed 

by  chromolysis  resulting  from  the  continuation  of  the 
stimulus 35 

2.  A.  section  of  normal  cerebellum  of  rabbit  (X100);   B, 

section  of  cerebellum  of  rabbil  after  insomnia—  109  hours 
(X100) 37 

3.  A,  section  of  normal  cerebellum  of  rabbil   (>  1600);    B, 

section  of  cerebellum  of  rabbil   after  insomnia     109 

hours  I  X1600) 39 

1.  A,  section  of  normal  liver  of  rabbit  (X100);  B,  section  of 
liver  of  rabbit  after  insomnia     109  hours  (X 100) 41 

5.  A.,  section  of  normal  liver  of  rabbit  (X1600  ;  B,  section  of 

liver  of  rabbit  after  insomnia   -109  hour-  I   ■   L600)  .       ,       L3 

6.  A.  section  of  normal  suprarenal  of  rabbil   (X100);    B, 

section  of  suprarenal  of  rabbil  after  insomnia     109  hours 

(X100) !•"> 

7.  A.  section  of  aormal  suprarenal  of  rabbit  (X1600);    B, 

Bed  urn  of  suprarenal  of  rabbil  after  insomnia      109  hours 

(X1600) 17 

8.  Comparison  of  the  aormal  brain-cells  with  the  brain- 

cells  <>f  a  <lo<j,  subjected  to  shock-producing  trauma 

under  ether-anesthesia 51 

'.).  Comparison  of  the  normal  brain-cells  with  the  brain-cells 

of  "spinal  'In-"  after  shock-producing  trauma 53 

10.  Differentia]  Purkinje  cell  counts  showing  the  percentage 

ol   active,   fatigued,   and   exhausted   cells   in   "Spinal 
Dogs"  after  attempts  t<>  produce  shock  by  trauma  55 

11.  Changes  seen  in  brain-cells  of  a  rabbil  subjected  to  fear        57 

12.  I  !annon  tesl  for  adrenalin,  showing  reaction  of  the  supra- 

renal glands  to  si  imulal  ion     fear  59 

13.  Area  from  cerebellum     delirium  tremens.     Showing  effect 

on  brain-cells  of  continued  stimulation  with  alcohol  iii 

I  l.  <  '.-in 1 1< H i  test,  showing  the  reaction  of  the  suprarenal  glands 

tn  -t  imulation      ana|>h\  la\i-  63 

15.    Activation    of    kinetic    system    caused    b)    injection    of 
skatol  . 

13 


14  LIST    OF   ILLUSTRATIONS 

FIG  PAGE 

16.  Cannon  test  for  adrenalin,  showing  lack  of  reaction  to 

stimulation  after  removal  of  suprarenal 69 

17.  Comparison    of    the    brain-cell    changes     produced    by 

anaphylaxis  alone  and  under  heavy  morphin  dosage.  .     71 

18.  Symbiotic  shock.     Experiment.     Diagram  showing  anas- 

tomosis of  the  circulation  of  Dog  A  and  Dog  B 73 

19.  Symbiotic    shock.     Experiment.     The    cerebellum    from 

the  untraumatized  dog  (recipient)  and  from  the  trauma- 
tized dog  (donor) 75 

20.  Differential   Purkinje   cell   counts.     Comparison   of   the 

effects  of  shock  under  ether  anesthesia  and  under 
nitrous-oxid-oxygen  anesthesia 77 

21.  Chart  compiled  from  laboratory  experiments  illustrating 

the  protective  effect  of  nitrous-oxid-oxygen  anesthesia 

in  cases  of  hypotension 78 

22.  Athlete:   Note  the  activation  of  his  motor  mechanism  as 

portrayed  in  his  facial  expression 83 

23.  Effect  of  strong  emotion — fear — upon  the  pulse 97 

24.  Schematic  drawing  illustrating  protective  effect  of  anoci- 

association Ill 

25.  Moynihan  Syringe  for  the  infiltration  of  quinin  and  urea 

hydrochlorid  at  a  distance  from  the  incision 119 

26    Abdominal    operations:     Infiltration    of    skin    and    sub- 
cutaneous tissues  with  novocain 123 

27.  Abdominal  operations:    Infiltration  of  fascia  and  muscle 

with  novocain 126 

28.  Abdominal  operations:    Infiltration  of  posterior   sheath 

and  peritoneum  with  novocain 127 

29.  Abdominal  operations:   Infiltration  with  quinin  and  urea 

hydrochlorid  at  a  distance  from  the  incision 128 

30.  Completely  relaxed  abdominal  wall  and  intestines,  the 

result  of  anoci-association 129 

31.  Comparative  clinical  results  of  consecutive  cholecystos- 

tomies  performed  under  ether  anesthesia,  under  nitrous- 
oxid-oxygen  alone,  and  under  complete  anoci-associa- 
tion     134 

32.  Chart  showing  the  uneventful  clinical  course  after  an 

operation  for  common  duct  stone  performed  under 
anoci-association 137 

33.  Comparative    clinical    results    of    consecutive    appendec- 

tomies performed  under  ether  anesthesia,  under  nitrous- 
oxid-oxygen  alone,  and  under  complete  anoci-association  149 


LIST    OF   ILLUSTRATIONS  15 


PAGE 


34.  Bladder  operations:  Infiltration  of  skin  with  novocain.  ..  .    161 

35.  Bladder  operations:    Infiltration  of  bladder  wall  before 

opening 163 

36.  Prostatectomy:    Intravesical  exposure  of  the  prostate.  .  .   165 

37.  Prostatectomy:   Infiltration  of  capsule  of  prostate  gland 

before  removal 167 

38.  Prostatectomy:     Cavity    left    after    enucleation    of    the 

prostate L69 

39.  Prostatectomy:    Gauze  packing  by  which  the  raw  sur- 

faces of  the  capsule  are  brought  in  apposition 171 

40.  Comparative   clinical   results  of  consecutive   abdominal 

hysterectomies  performed  under  ether  anesthesia, under 
nitrous-oxid-oxygen  alone,  and  under  complete  anoci- 
association 178 

41.  Laryngectomy:     Schematic    drawing    to    illustrate    the 

method  of  packing  the  lateral  planes  of  neck  with  iodo- 
form gauze  at  preliminary  operation 180 

42.  Laryngectomy:    Infiltration  of  skin  with  novocain 1M 

I:;.   Laryngectomy:   Infiltration  of  fascia  with  novocain 183 

ll.  Laryngectomy:    Noyocainizing  the  nerve-endings  of  the 

trachea ls-> 

15.  Laryngectomy:  Schematic  drawing  Bhowing  arrange- 
ment of  tube  through  which  the  inhalation  anesthesia  is 
administered  and  also  the  shoemaker's  stitch  used  in 

closing  pharyngeal  opening lss 

Hi.  Typical  case  of  exophthalmic  goiter  showing  character- 
istic fades 1 93 

17.  Thyroidectomy:  infiltration  of  skin 195 

is.  Thyroidectomy:   infiltration  of  muscle  before  division .       L95 
19.  Thyroidectomy:    Bloodless  division  of  muscles  betweeja 

clamp-  196 

50.  Comparative   clinical    results   of  consecutive   thyroidec- 

tomies performed  under  ether,  under  nitrous-oxid- 
oxygen  alone,  and  under  complete  anoci-association         197 

51.  ('hart    illustrating   protection  offered   by   use  of   anoci- 

association   in   thyroidectomy  197 

52.  The  pulse-rate  immediately  before  and  immediately  after 

operation  213 

53.  Comparative   clinical    results  of  consecutive  operations 

performed  under  ether,  under  nitrous-oxid-oxygen,  and 

under  complete  a  noci-a  -  -ocia  t  ion  213 


16  LIST    OF    ILLUSTRATIONS 


PAGE 


54.  Comparison  of  the  mortality  rate  of  all  operations  per- 

formed at  Lakeside  Hospital  by  the  authors  and  their 
resident  staff  during  1908  with  the  mortality  rate  of  the 
last  two  years,  1912  and  1913 221 

55.  Nitrous-oxid-oxygen  anesthesia.     Patient  in  dorsal  posi- 

tion     233 

56.  Nitrous-oxid-oxygen  anesthesia.     Patient  in  lateral  posi- 

tion.    Mask  held  in  place  by  linen  cloth 235 

57.  Nitrous-oxid-oxygen  anesthesia.     Patient  in  prone  posi- 

tion, mask  held  in  place  by  linen  cloth 237 

58.  Nitrous-oxid-oxygen    anesthesia,    showing   use    of   nasal 

tubes  in  face,  mouth,  and  neck  operations 241 

59.  Diagram  showing  apparatus  installed  in  Lakeside  Hos- 

pital for  the  manufacture  of  nitrous  oxid (facing)  252 

60.  Diagram  showing  operating-room  arrangement  of  nitrous- 

oxid-oxygen  apparatus  as  installed  at  Lakeside  Hospital  253 


[NTRODUCTION 

l?v  GEORGE  W.  CRILE,  M.  I). 


THE  EVOLUTION  OF  THE  KINETIC  THEORY  OF  SHOCK 
AND  THE  SHOCKLESS  OPERATION 

The  desire  to  discover  the  cause  of  surgical  shock  led  us 
in  1893  to  the  experimental  investigation  of  the  comparative 
effects  on  the  blood-pressure  and  respiration  of  traumatism 
of  different  kinds  and  of  varying  degrees  of  intensity  in- 
flicted upon  various  parts  and  organs  of  the  body.  These 
researches  were  published  in  detail  in  1897  in  a  monograph.* 
AlS  a  result  of  these  investigations  we  concluded  that  shock 
was  the  result  of  exhaustion  and  since,  from  the  surgeon's 
point  of  view,  the  most  vital  phenomenon  accompanying 
shock  was  a  low  blood-pressure,  we  concluded  at  that  time 
thai  the  mosl  importanl  effecl  of  traumatism  was  the  im- 
pairment of  the  vasomotor  mechanism. 

Later  we  investigated  various  methods  by  which  shock 
might  be  prevented  and  found  thai  the  shock  phenomena 
did  not  follow  injuries  in  territories  the  nerve  supply  of 
which  was  blocked;  that  is,  blocking  the  spinal  cord  pre- 
vented -hock  from  traumatization  in  the  blocked  area. 

After  investigating  many  drugs  and  following  many 
different  lino  of  research,  we  concluded  thai  shock  was  mosl 
conspicuously  diminished  by  morphin  administered  hypo- 
dermically  and  by  local  and  regional  anesthesia.  We  found, 
however,  thai  careful  handling,  sharp  dissection,  and  mini- 
mum trauma  :1b"  were  effective  in  preventing  shock. 

These  later  investigations,  published  in   1901,1  laid   the 

1.   W.  Crile:  \n  Experimental  Research  into  Surgical  Shock. 
t(i.  \\    ('nlr:    \n    Experimental   and    Clinical    Research    into  Certain 
Probli  hi    Relating  '"  Surgical  <  Operations. 

19 


20  ANOCI-ASSOCIATION 

foundation  for  the  development  of  the  preventive  technique 
which  we  later  designated  anoci-association. 

In  our  belief  that  the  most  vital  effect  of  shock  was  the 
impairment  of  the  vasomotor  mechanism,  we  next  directed 
our  attention  to  the  maintenance  of  the  blood-pressure. 
We  found  that  as  long  as  an  animal's  blood-pressure  was 
maintained  within  certain  limits,  we  could  sustain  life; 
logically  then  if  we  could  devise  some  means  by  which  the 
blood-pressure  could  be  maintained,  we  could  overcome  the 
disastrous  effects  of  shock. 

A  research  was  made  upon  the  effect  of  strychnin,  and  it 
was  discovered  that  this  stimulating  drug  not  only  did  not 
improve  the  condition  of  the  animal  after  shock,  but  actually 
made  it  worse.  At  the  end  of  that  research,  therefore,  we 
concluded  that  shock  could  be  produced  by  strychnin  alone, 
and  that  it  was  as  logical  to  treat  traumatic  shock  with  strychnin 
as  it  would  be  to  treat  strychnin  shock  with  trauma. 

As  the  field  of  stimulants  offered  no  valuable  remedy,  we 
then  endeavored  to  maintain  the  blood-pressure  by  apply- 
ing pressure  to  different  parts  of  the  body,  and  we  found 
that  we  could  raise  the  blood-pressure  by  local  bandag- 
ing. As  a  result  of  these  experiments,  we  finally  devised 
the  pneumatic  suit,  by  means  of  which  the  general  blood- 
pressure  could  be  raised  at  will  within  a  range  of  from  15  to 
45  mm.  of  mercury.  This  was  used  at  Lakeside  Hospital 
for  a  time,  but  it  was  not  an  easy  working  method,  for  the 
suit  was  cumbersome  and  uncomfortable  and  valuable  time 
was  lost  in  putting  it  on. 

We  also  made  an  extensive  research  in  the  hope  that  by 
increasing  the  atmospheric  pressure  of  a  room  in  which  the 
patient  could  be  placed  the  blood  could  be  pressed  to  the 


EVOLUTION    OF    KINETIC    THEORY    OF    SHOCK  21 

inner  organs  and  to  the  brain.  In  these  experiments  we 
used  a  metallic  cylinder  and  tried  the  effect  of  variations  in 
the  atmospheric  pressure.  We  found  that  the  air  pressure 
was  transmitted  through  the  body  equally  and  that,  there- 
fore, by  this  means  we  could  not  increase  the  general  blood- 
pressure. 

We  then  tried  the  effect  of  increased  air  pressure  upon  all 
of  the  body  excepting  the  intrapulmonary  tract,  hoping 
thereby  to  overcome  low  blood-pressure  by  forcing  an  ade- 
quate volume  of  blood  back  to  the  heart.  By  placing  an 
animal  in  an  air-tight  metal  cylinder  and  tying  into  the 
trachea  a  tube  which  passed  out  to  the  external  air.  we  were 
able  to  increase  the  air  pressure  upon  the  entire  body  while 
the  air  within  the  pulmonary  tract  remained  constantly  at 
the  atmospheric  pressure  of  the  room.  By  this  means  the 
blood  could  be  driven  rapidly  from  the  periphery  into  the 
thorax.  We  encountered,  however,  a  difficulty  which  we 
had  not  anticipated:  the  heart  was  so  rapidly  filled  and  its 
work  so  suddenly  increased  that  dilation  readily  occurred; 
for,  when  the  amount  of  blood  driven  to  the  auricle-  is 
doubled,  the  work  of  the  heart  is  increased  fourfold. 

We  were  unable  to  find  any  mechanism  by  means  of  which 
we  could  with  sullicient  delicacy  control  the  air  pressure  in 
all  parts  of  the  body  bul  the  thorax,  so  that  the  heart  could 
take  cure  of  its  added   work   without    danger  of  immediate 

paralysis.  We  even  went  so  far  as  to  have  an  air-tight 
chamber  built  in  the  hospital,  but  on  account  of  the  diffi- 
culties of  compression  and  decompression  this  was  found 
impract  icable. 

Having  failed  to  establish  any  valuable  therapeutic  action 
in  drugs,  in  direct  mechanical  pressure  on  the  body,  or  in 


22  ANOCI-ASSOCIATION 

increased  air  pressure,  we  turned  to  the  treatment  of  shock 
by  means  of  infusions.  It  was  obvious  that  in  shock  the 
blood  becomes  massed  in  the  larger  venous  trunks,  especially 
in  those  in  the  abdomen  and  the  chest.  We  argued  that  if 
we  could  fill  the  collapsed  circulatory  system,  we  could 
raise  the  blood-pressure,  and  so  prevent  the  damaging 
anemia  of  the  brain. 

We  experimented  with  various  artificial  methods,  with 
Locke's  and  Ringer's  solutions  and  with  saline  solution,  but 
in  every  case  we  found  that  it  was  impossible  to  do  more 
than  raise  the  blood-pressure  temporarily.  We  found  that, 
whatever  the  rate  of  infusion,  the  hemoglobin  estimation 
and  the  red  blood  cell  counts  showed  that  the  blood  was  not 
diluted.  We  then  tested  the  effect  of  rapid  intravenous  in- 
fusion with  indefinite  quantities  of  these  solutions.  The 
animals  died  in  from  five  to  eight  minutes  after  sufficiently 
large  infusions.  The  solutions  passed  through  the  vessel 
walls  as  fast  as  they  entered.  The  abdomen  distended  rap- 
idly and  became  hard  and  tense.  Autopsies  showed  that  the 
fluid  had  accumulated  in  the  walls  and  lumina  of  the  stom- 
ach and  the  intestines,  in  the  liver  and  the  spleen,  thus 
mechanically  fixing  the  diaphragm  and  the  floating  ribs  so 
that  death  was  caused  by  asphyxia. 

All  of  these  results  made  it  increasingly  obvious  that  an 
agent  must  be  found  which  could  increase  the  peripheral 
resistance  so  that  for  a  time  it  would  take  the  place  of  the 
impaired  vasomotor  mechanism.  Adrenalin  accomplished 
this  result  immediately.  By  employing  a  continuous  in- 
travenous infusion  of  a  1  :  50,000  solution  of  P.  D.  &  Co.'s 
adrenalin  at  the  rate  of  3  c.c.  per  minute  it  was  possible 
to  maintain  the  blood-pressure  for  many  hours. 


EVOLUTION    OF   KINETIC    THEORY    OF    SHOCK  23 

By  the  use  of  adrenalin  alone  the  circulation  in  a  decapi- 
tated dog  was  maintained  for  eleven  hours.  Adrenalin 
infusions  were  found  effective  in  human  cases  but  the  ob- 
vious difficulties  and  dangers  in  its  use  led  us  to  continue  the 
search  for  a  better  therapeutic  agent  by  means  of  which  the 
blood-pressure  could  be  maintained. 

From  all  of  these  observations  we  concluded  that  the 
ideal  treatment  would  be  to  fill  the  blood-vessels  with  some 
fluid  which  would  not  pass  through  the  vessel  walls,  would 
cause  no  chemical  injury,  would  carry  oxygen,  and  would 
always  be  immediately  available.  Human  blood  is  the  only 
fluid  which  possesses  all  of  these  qualifications. 

After  a  long  research  we  devised  a  method  by  which  the 
circulation  of  one  animal  could  be  connected  with  that  of 
another  so  that  blood  could  be  transmitted  at  will  from  one 
to  the  other  and  we  found  that  as  long  as  the  heart  could  do 
it>  work,  the  blood-pressure  could  be  raised  and  maintained 
indefinitely  through  the  transfusion  of  blood.  An  over- 
transfused  animal  could  be  decapitated  even  without  re- 
sultant change  in  its  blood-pressure.  If  artificial  respiration 
were  maintained  then  the  blood-pressure  did  not  fall  for 
half  a  day  or  Longer.  If  an  animal  were  overtransfused  one 
day  and  decapitated  the  next,  its  blood-pressure  did  not  fall. 
These  experiments  showed  that  the  elasticity  of  the  over-dis- 
tended blood-vessels  supplied  the  peripheral  resistance  nor- 
mally maintained  l>v  the  vasomotor  mechanism. 

'This  experimental  research  yielded  the  ideal  treatment 
for  surgical  Bhock     the  direct  transfusion  of  blood. 

Having  established  an  efficient  treatment  for  shock,  we 
turned  our  attention  once  more  to  an  investigation  oi  the 
cause  and  the  pathology  of  Bhock.     \\V  had  hum  ere  this 


24  ANOCI-ASSOCIATION 

observed  in  our  experiments  that  the  use  of  cocain  as  a  local 
anesthetic  in  some  measure  diminished  shock,  and  in  1900, 
Dr.  Lower  made  use  of  spinal  analgesia  for  the  purpose  of 
preventing  shock.  These  clinical  observations  and  our  labo- 
ratory researches  convinced  me  that  in  shock  the  brain-cells 
must  show  morphologic  changes  analogous  to  the  changes  seen 
by  Hodge  in  the  nerve-cells  of  bees  and  birds.  To  this  end  I 
asked  Dr.  D.  H.  Dolley,  who  was  then  associated  with  me,  to 
make  a  histologic  study  of  the  brains  of  dogs  after  traumatic 
shock  and  of  rabbits  after  emotional  shock.  Since  Dr.  Dolley's 
departure  for  a  distant  post  these  nerve-cell  investigations 
have  been  continued  by  Dr.  J.  B.  Austin  to  the  present  time. 
As  will  be  seen  in  the  following  chapters,  the  brain-cell 
changes  give  an  excellent  index  to  the  degree  of  shock,  not 
only  of  shock  from  trauma  and  from  emotion,  but  of  drug 
shock,  toxic  shock,  anaphylactic  and  foreign  proteid  shock. 

Believing  that  the  changes  in  the  brain-cells  were  work 
changes,  we  then  studied  other  organs  whose  functions  seemed 
to  indicate  that  they  were  closely  related  to  the  brain  in  its 
activities.  And  finally,  we  threw  out  our  net  of  inquiry  so  as 
to  include  every  tissue  and  organ  of  the  body  and  found  that 
exhaustion  from  insomnia,  from  muscular  exertion,  from 
emotional  excitation,  from  physical  injury,  from  anaphylaxis, 
all  cause  histologic  changes  in  the  brain,  the  suprarenals,  and 
the  liver,  and  that  these  stimuli  do  not  cause  histologic  changes 
in  any  other  organ. 

Our  researches  have  shown  also  that  in  shock  the  H-ion 
concentration  of  the  blood  is  increased.  This  significant  fact 
will  be  elaborated  in  later  monographs. 

Thus,  after  many  years  of  investigation  and  experimen- 
tation we  have  come  at  last  not  only  to  an  expanded  con- 


EVOLUTION    OF   KINETIC    THEORY    OF    SHOCK  2.") 

ception  of  the  causation  of  surgical  shock,  but  also  to  a  gen- 
eralization regarding  exhaustion  from  the  most  varied 
causes,  and  an  unexpected  insight  into  the  origin  of  certain 
diseases. 

In  the  following  pages  we  confine  ourselves  for  the  most 
pari  to  the  brain-cell  changes  produced  by  the  trauma  and 
environment  attending  surgical  operations,  but  it  should  be 
borne  in  mind  that  these  brain-cell  changes  are  an  index  to 
the  changes  which  the  same  causes  are  producing  in  the 
Buprarenals  and  the  liver. 

It  should  be  stated  also  that  our  kinetic  theory  of  shock 
and  exhaustion  does  not  rest  entirely  upon  laboratory  re- 
searches. The  results  of  laboratory  experimentation  can 
become  of  practical  value  only  when  tried  in  the  crucible  of 
the  clinic.  In  the  formulation  and  the  application  of  the 
kinetic  theory  of  shock  we  have  drawn  upon  the  knowledge 
gained  by  the  practical  experience  of  our  colleagues  and  our- 
selves in  the  operating  room  and  at  the  bedside  of  our 
patients. 


PART  I 

THE  KINETIC  THEORY  OF  SHOCK  AND 
ANOCI-ASSOCIATION 

By  GEORGE  W.  CHILE.  M.D. 


CHAPTER  I 

THE  KINETIC  THEORY  OF  SHOCK 

THE  KINETIC  THEORY  OF  SHOCK— GENERAL  STATEMENT 

When  a  barefoot  boy  steps  on  a  sharp  stone  there  is  an 
immediate  discharge  of  nervous  energy  in  his  effort  to  escape 
from  injury.  This  is  not  a  voluntary  act.  It  is  not  due  to 
his  own  personal  experience  (his  ontogeny)  but  is  the  result 
of  the  experience  of  his  progenitors  during  the  vast  periods 
of  time  required  for  the  evolution  of  his  species  (his  phylo- 
geny).  The  wounding  stone  made  an  impression  upon  the 
nerve  receptors  in  the  foot  similar  to  the  innumerable  in- 
juries which  gave  origin  to  this  nerve  mechanism  Itself  dur- 
ing the  boy's  vast  phylogenetic  or  ancestral  experience. 
The  stone  supplied  the  phylogenetic  association  and  the 
appropriate  discharge  of  nervous  energy  automatically  fol- 
lowed. 

In  like  manner  all  actions  are  performed.  Every  adequate 
stimulus  awakens  an  ontogenetic  or  phylogenetic  memory 
or  association,  and  the  nerve  mechanism  evolved  by  count- 
less similar  experiences  in  the  life  of  the  individual  or  of  his 
race  makes  the  appropriate  response.  These  associations, 
like  thai  awakened  by  the  sharp  -tone  in  our  illustration, 
may  be  injurious  to  the  individual  noci-associations;  or 
t  hey  may  be  of  benefit  to  the  individual  hence  >»  ru  -associa- 
tions. The  sighl  of  appetizing  food  is  a  bene-association 
it  awaken-  both  the  phylogenetic  and  the  ontogenetic  mem- 
ory of  similar  experiences.     The  nerve  centers  are  stimulated 


30  ANOCI-ASSOCIATION 

as  if  the  food  were  actually  being  eaten — and  the  "mouth 
waters." 

All  of  life,  therefore,  is  made  up  of  bene-  and  noci-associa- 
tions  and  the  constant  effort  of  the  race  and  of  the  individual 
is  to  increase  the  former  and  decrease  the  latter,  to  develop 
an  environment  which  shall  as  far  as  possible  be  free  from 
nod-associations — to  reach  a  state  of  anoci-association. 

The  environmental  influences  that  threaten  annihilation, 
such  as  the  assaults  of  beasts  or  of  man  against  man;  the 
impacts  of  sharp,  rough,  and  moving  objects;  the  irrita- 
tions of  dust  and  debris  are  among  the  coarser,  nocuous  ele- 
ments, to  meet  which  there  have  been  evolved  in  man  adap- 
tive mechanisms  which  are  excited  to  activity  by  the  noci- 
ceptors, which  are  richly  implanted  in  the  skin.  The  nocu- 
ous effects  of  cold,  rain,  and  storm  are  met  by  other  adapta- 
tions— shelter,  clothing,  fire;  while  against  those  unseen 
nocuous  elements  which  cannot  be  perceived  by  the  senses 
—pathogenic  bacteria — the  body  has  evolved  chemical  de- 
fenses— antibodies,  immunity,  febrile  reaction,  phagocy- 
tosis. 

Thus  man  is  constantly  beset  by  noci-associations  and  as 
constantly  is  striving  to  reach  a  state  of  anoci-association. 
An  umbrella  in  a  rain-storm;  a  glowing  fireside  in  a  blizzard; 
bolts  and  bars  against  attack;  antitoxin  in  an  infection- 
all  are  attempts  to  produce  anoci  conditions.  In  the  be- 
ginning of  human  history,  however,  man  in  common  with 
most  animals  had  two  principal  methods  of  self-defense 
against  the  dangers  which  surrounded  him — he  fought  or 
he  ran  away.  It  is,  therefore,  the  motor  mechanism  in  par- 
ticular which  through  its  phylogenetic  association  with  in- 
jury to  the  individual  is  responsible  for  the  discharges  of 


THE   KINETIC   THEORY   OF   SHOCK  31 

energy  which  are  occasioned  by  the  presence  or  even  the 
thought  of  danger.  These  discharges  of  energy,  when  intense 
enough  or  protracted  enough,  produce  the  extreme  condi- 
tions called  "exhaustion"  and  ''shock."  In  other  words, 
shock  is  the  result  of  the  excessive  conversion  of  potential  into 
kinetic  energy  in  response  to  adequate  stimuli. 

According  to  this  conception — the  kinetic  theory  of  shock — 
the  essential  lesions  of  shock  are  in  the  cells  of  the  brain, 
the  suprarenals,  and  the  liver,  and  are  caused  by  the  con- 
version of  potential  energy  into  kinetic  energy  at  the  ex- 
pense of  certain  chemical  compounds  stored  in  the  cells 
of  the  brain,  the  suprarenals,  and  the  liver.  There  is  strong 
evidence  also  that  animals  capable  of  being  shocked  are 
animals  whose  self-preservation  originally  depended  upon 
some  form  of  motor  activity.  In  man  and  other  animal- 
this  motor  activity  expresses  it  se  It  in  running  "and  fighting; 
hence  the  motor  mechanism  comprises  the  muscles  and  the 
organs  that  contribute  to  their  activity. 

Motor  activity  then  is  excited  by  the  adequate  stimulation 
of  the  nerve  Ceptors,  both  of  the  contact  ceptors  in  the  -kin 
and   of  the  disliiiici    ceptors  or  -pecial   senses.      We  assume 

thai  stimulation  of  the  distance  ceptors  (special  senses    is 

;i-  potent  :t-  -t  in  nilat  ion  of  the  contact  ceptors  in  producing 
;i  discharge  i  »f  energy.  As  has  already  been  indicated,  we  as- 
sume also  that   the  environment   of  the  past   (phylogeny) 

through  the  experience-  of  adaptation  to  environment,  pre- 
determine- the  environmental  reaction-  of  the  present.  In 
each  individual  at  a  given  time  there  is  a  limited  amount  of 
potential  energy  Btored  in  the  brain,  the  suprarenals,  and  the 
liver.  Motor  activity,  expressed  as  action  or  emotion,  fol- 
lowing upon  each  stimulus,  whether  traumatic  or  psychic, 


32  ANOCI-ASSOCIATION 

diminishes  by  so  much  this  store  of  potential  energy.  Stim- 
uli of  sufficient  number  or  intensity  inevitably  cause  exhaus- 
tion or  death  even.  If  this  motor  activity,  resulting  from 
responses  to  stimuli,  takes  the  form  of  obvious  work  per- 
formed, such  as  running,  the  phenomena  expressing  the  de- 
pletion of  the  vital  force  are  termed  physical  exhaustion. 
If  the  expenditure  of  vital  force  is  due  to  traumatic  or  to 
psychic  stimuli  which  lead  to  no  obvious  work  performed, 
especially  if  the  stimuli  are  strong  and  the  expenditure  of 
energy  is  rapid — the  condition  is  designated  "shock." 

Shock  or  exhaustion,  therefore,  may  be  produced  by  di- 
verse causes,  such  as  fear  and  worry,  physical  injury,  infec- 
tion, hemorrhage,  excessive  muscular  exertion,  starvation, 
insomnia.  We  shall  present  evidence  that  all  of  these  con- 
ditions cause  physical  alterations  in  the  cells  of  the  brain, 
the  suprarenals,  and  the  liver,  that  these  physical  changes 
are  identical,  whatever  their  cause;  and  that  those  cells 
which  reach  a  certain  degree  of  alteration  cannot  be  restored, 
but  go  on  to  annihilation.  The  histologic  changes  in  the 
brain,  the  suprarenals,  and  the  liver  may  be  caused  by  emo- 
tion alone,  by  physical  injury  alone,  by  hemorrhage  alone, 
by  starvation  alone,  by  insomnia  alone;  or  these  changes 
may  be  started  by  emotion,  carried  a  step  further  by  mus- 
cular exertion,  another  step  by  physical  injury,  another  by 
hemorrhage,  and  so  on  until  they  are  destroyed;  or  all  of 
these  factors  acting  simultaneously  may  produce  the  same 
disastrous  result.  There  is  no  microscopical  evidence  of 
specificity  in  the  effects  of  these  various  factors;  that  is, 
no  one  could  look  at  an  altered  brain-cell,  suprarenal  cell  or 
liver  cell  under  the  microscope  and  be  able  to  state  the  cause 
of  its  structural  change.  These  changes  in  shock  and  ex- 
haustion from  any  cause  whatsoever  seem  to  be  identical. 


THE    KINETIC    THEORY    OF    SHCM  K  33 

If  the  cytoplasm  be  regarded  as  the  index  of  the  po- 
tential energy  stored  in  the  cell,  it  is  easy  to  comprehend 
the  identical  changes  ultimately  wrought  by  factors  that 
diminish  the  stores  of  energy.  The  physical  stale  of  the  ar- 
senal is  identical  however  the  ammunition  has  been  ex- 
hausted, whether  it  has  been  stolen  or  fired.  For  our  thesis 
we  may  consider  the  brain,  the  suprarenals,  and  the  liver 
as  the  magazine,  the  cytoplasm  as  the  powder,  and  ade- 
quate stimuli,  however  produced,  as  the  means  by  which 
rounds  of  ammunition  are  withdrawn. 

Although,  as  already  stated,  all  of  life  is  filled  with  nod- 
associations,  as  a  result  of  which  the  stored  energies  of  the 
body  are  being  constantly  drained,  in  this  monograph  we 
shall  consider  first  the  pathology  of  traumatic  shock;  of 
emotional  -hock:  of  toxin  and  foreign  proteid  shock:  and 
of  drug  -hock,  and  then  the  practical  application  of  the  ki- 
netic theory  of  shock  in  the  development  of  the  shockless 
>  iperal  ion  through  anoci-association. 


CHAPTER  II 
THE  HISTOLOGIC  PATHOLOGY  OF  SHOCK 

Traumatic  Shock.  Emotional  Shock.  Toxic,  Foreign  Proteid,  and  Anaphy- 
lactic Shock.  Drugs — Anesthetics,  Narcotics,  and  Stimulants.  Anemia. 
Are  the  Cell  Changes  Seen  in  Shock  due  to  the  Products  of  Pathologic 
Metabolism,  or  to  Altered  Gases  in  the  Blood?  The  Influence  of  the  Inhala- 
tion Anesthetics  upon  Shock-Production. 

The  kinetic  theory  of  shock,  as  has  already  been  indicated, 
postulates  that  all  forms  of  shock  are  caused  by  over-stimu- 
lation and  consequent  exhaustion;  that  the  cells  of  the 
brain,  the  suprarenals,  and  the  liver  show  physical  changes 
corresponding  to  each  change  in  the  clinical  cycle  of  shock; 
that  each  shock-producing  agency  causes  in  the  cells  of 
the  brain  a  hyperchromatic  stage  followed  by  a  hypochromatic 
stage  (Fig.  1). 

The  organs  of  the  body  especially  involved  in  shock  are 
certain  organs  whose  function  is  that  of  converting  latent 
energy  into  kinetic  energy  in  response  to  adaptive  stimula- 
tion. These  organs,  among  which  are  the  brain,  the  thy- 
roid, the  suprarenals,  the  liver,  and  the  muscles,  have  been 
designated  the  kinetic  system  because  of  this  peculiarly  ki- 
netic function.  In  response  to  environmental  stimuli  of  any 
sort  these  organs  convert  latent  energy  into  motion  or  into 
heat.  Here,  however,  we  shall  consider  only  the  conversion 
of  latent  energy  into  motion  as  a  response  to  the  need  for 
self-preservation  against  physical  injury. 

As  evidence,  we  shall  present  clinical  and  experimental 
observations  of  the  energy-producing  results  of  insomnia; 

34 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


35 


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THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


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THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK  49 

of  physical  injury  alone;  of  physical  injury  under  inhalation 
anesthesia;  of  the  emotional  stimulation  of  fear  alone;  and 
of  foreign  proteid  and  toxic  stimulation  alone. 

In  our  initial  researches  a  working  histologic  standard  for 
the  brain  was  established  and  compared  in  a  large  number  of 
brains  with  the  immediate  and  later  effects  of  physical  in- 
jury under  inhalation  anesthesia  in  intact  dogs  and  in  "spinal 
dogs"*  of  physical  injury  in  dogs  with  crossed  circulation; 
and  of  physical  injury  wit  liin  t  he  territory  of  local  anesthesia ; 
of  injections  of  toxins;  of  injections  of  stiychnin  and  nior- 
phin;  of  various  inhalation  anesthetics;  of  severe  hemor- 
rhage and  of  fatigue  from  both  physical  exertion  and  pro- 
longed wakefulness. 

These  comparative  histologic  studies  were  later  extended 
to  include  the  suprarenals  and  the  liver,  these  organs,  as 
already  stated,  being  the  only  organs  besides  the  brain  whose 
Cells  showed  immediate  structural  changes  after  prolonged 
stimulation  from  any  cause. 

In  this  thesis  we  shall  describe  in  detail  the  brain-cell 
changes  only.  The  reader  should  bear  in  mind,  however, 
thai  in  every  ease  the  cells  of  the  suprarenals  and  of  the  liver 
showed  corresponding  changes    Figs.  2-7). 

TRAUMATIC  SHOCK 
When  physical  injury  alone  was  inflicted  Oil  normal  dogs 
under  inhalation  anesthesia,  a  certain  Dumber  of  the  brain- 
cells  showed  firsl  a  stage  of  hyperactivity  characterized  by 
hyperchr al  ism;  and  later  a  stage  of  exhaustion  character- 
Spinal  dogB"  are  doge  w  hose  Bpinal  cords  have  been  divided  al  the  level 
of  tin'  first  dorsal  Begmenl  so  thai  the  abdomen  and  hind  extremities  have  no 
direct  nerve  connection  with  the  brain. 

\firr  two  months  or  more  these  animals,  if  kept  in  good  condition,  will 
.-huw  .1  return  of  the  spinal  reflexes,     the  "scratch  reflex"  for  example. 
i 


50  ANOCI-ASSOCIATION 

ized  (a)  by  chromatolysis;  (b)  by  alteration  of  nucleus- 
plasma  relation;  (c)  by  rupture  of  the  nuclear  and  the  cell 
membranes  and  finally  (d)  by  disintegration  (Fig.  8). 
These  changes  were  most  marked  in  the  cortex  and  the  cere- 
bellum, but  were  present  also  in  the  medulla  and  the  cord. 

The  brain-cells  showed  no  change  when  the  trauma  was 
limited  to  territories  disconnected  from  the  brain  by  sever- 
ing the  spinal  cord,  or  by  local  anesthetization  (Figs.  9  and 
10).  When  the  circulations  of  two  dogs  were  crossed  and 
but  one  dog  was  traumatized,  brain-cell  changes  were  found 
only  in  the  dog  traumatized.  Dogs  overtransfused — to  elim- 
inate the  factor  of  anemia — and  traumatized  showed 
brain-cell  changes.  When  the  vitality  had  been  previously 
reduced  by  emotion,  by  physical  exertion,  by  toxins,  by  in- 
fection, by  hemorrhage,  by  excessive  thyroid  feeding,  by 
adrenalectomy — or  by  any  cause  that  reduces  the  vital  power 
— greater  changes  were  found  after  equal  trauma,  the  en- 
durance of  the  animal  being  in  proportion  to  its  vitality  at 
the  beginning  of  the  experiment.  We  found  that  trauma 
under  curare  caused  no  more  brain-cell  changes  than  ap- 
proximately equal  trauma  under  ether. 

From  these  observations  we  conclude  that  ether  anes- 
thesia offers  no  protection  to  the  brain-cells  against  the 
effect  of  trauma  and  that  the  lipoid-solvent  anesthetics  prob- 
ably break  the  arc  which  maintains  consciousness  beyond 
the  brain-cells  somewhere  in  the  efferent  path.  The  afferent 
path  from  the  seat  of  injury  being  unbroken,  the  afferent  stim- 
uli reach  and  modify  the  brain-cells  as  readily  as  if  no  anes- 
thetic had  been  given,  and  it  would  seem  that  the  brain-cell 
changes  must  be  due  to  the  discharge  of  energy  in  a  futile  effort 
to  escape  from  the  injury. 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


51 


A 


#; 


■ 


~~$ 





• 

• 
• 

. 

• 

■ 

in  normal  oerebellura  "i  ■  '!"«■ 


Irea  ii the  cerebellum  of  :i  dog  -u  In- 
jected to  shock-produoing  trauma  under 
•  i  I  hi  ancsl  l" 


I  i'.   8     Comparison  01    ran  Normal  Brain-celi     u m    Brain-cells 

hi    \  Dog  Subjected  ro  Shock-producing  Trauma  under  Etueb  Ineb- 

i  in    i  \ 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


53 


■ 

fljaB    ' 

' 

• 

c 

ft 

P 

' 

• 

Area  from  normal  i  erebellum  ol 


1  m  Hum  ..I    " ipinal 
•  iii-r    shock-producing    trauma 
compare  «  ith  I  ia    v 


Fig  9.    Comparison Normal  Brain-cellb  with  phi    Brain-cells 

oi    "Spinal  Doq"   ifteh  Shock-producing  Trauma 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


55 


7o 

10 

10    30 

IfO 

SO 

60 

70 

80 

90 

Att'we 

%P 

-nsJI'D  o 

H.aTTn'a.l 

F«.ti^u.edL. 

Vl 

■n^l' 

;D«< 

: 

Jlo 

r  m  a 

Hv\\*.x<>te<L 

Spi 

Lr 

Do< 

Ho 

-  -m  a 

.1 

Attempted  shock  of  a  do«  immediately  after  severing  tin-  spinal  cord  at  the  seventh  cervical 

vertebra. 


% 

10 

lo|    30 

1*0 

SO 

GO 

70 

80 

90 

Active. 

"ri 

\^% 

fu« 

| 

)TTT 

a.\  • 

Fa_t  i  *aedl 

\ 

in  a 

I'd 

»f. 

"hir-ir 

9.1 

Exha-aSted, 

"&P 

it  t, 

5o^ 

_ 

:  - 

rim 

ul 

Attempted  shook  of  a  dog  two  and  one-half  months  after  severing  the  spinal  oord  at  the  seventh 

cervical  verl 

The  dog's  spinal  oord  was  levered  .-it  the  seventh  cervical  vertebra,  recovery  following  after 
a  stormy  convalescence.      \<  the  end  of  two  and  one-half  months  the  dog  was  given  ether,  and 
bock-producing  manipulations  were  carried  on  for  four  hours.  \'  the  beginning  and  end  •  •( 
ti„-  experiment,  burning  both  a  front  and  a  hind  paw  caused  practically  no  vasomotor  reaction, 
as  shown  bj  the  blood  ""'  rising.     Moreover,  at  the  end  of  tl spenmont  the  blood- 

had  fallen  onlj  8  mm.  of  mercury.     I  lamination  of  the  cord  at  the  point  "i  division 
showed  onlj  •  The  differential  Purkinie  cell  count  showed  byperchromatism  and 

rue  or  exhaustion  of  consequence.     Hence  the  shock-producing  afferent   unpul 
i  by  the  break  in  the  oord  and  no  shock  followed. 

I  ■',,..  in     Dm  i  i,i  mi  \i.  l'i  rkinje  Cell  Coi  NTS  Showing  mi   Percentage 
,,,    \,  1 1\  i  .  i  \  i  k.i  iK,  \m»  Exhai  sted  Cells  in  "Spinal  Dogs"  utter 

\  i  1 1  \i |.|     in  i'i;i idtji  i   Sh< m  k  m  Ta  M  MA. 


56  ANOCI-ASSOCIATION 

EMOTIONAL  SHOCK 

Iii  rabbits  subjected  to  the  emotional  stimulus  of  fear 
alone, — without  accompanying  trauma  or  muscular  exer- 
tions,— the  brain-cells  show  precisely  the  same  changes  as 
those  which  result  from  physical  injury,  that  is,  an  immediate 
stage  of  hyperchromatism  and  a  later  stage  of  chromatoly- 
sis;  a  disturbance  of  the  nucleus-plasma  relation  and  the 
final  disintegration  of  many  cells  (Fig.  11). 

In  two  experiments  in  which  rabbits  were  subjected  to 
intense  fear  daily,  in  one  case  for  two  weeks  and  in  the  other 
for  three  weeks,  ten  per  cent,  of  the  Purkinje  cells  were  ac- 
tually destroyed.  In  cats  the  emotion  of  rage  caused  a 
striking  increase  in  the  output  of  adrenalin,  but  in  cats  sub- 
jected to  fear  and  rage  a  month  after  the  division  of  the 
major  and  minor  splanchnic  nerves,  there  was  no  increase 
in  the  output  of  adrenalin  (Fig.  12).  In  rabbits  acute  fear 
caused  a  rise  in  temperature  of  from  one  to  three  degrees, 
excepting  in  thyroidectomized  animals  whose  temperature 
remained  subnormal. 

TOXIC,  FOREIGN  PROTEID,  AND  ANAPHYLACTIC  SHOCK 
To  determine  the  histologic  changes  produced  by  toxic, 
foreign  proteid,  and  anaphylactic  shock,  the  brains  of  many 
human  beings  who  had  died  of  infections  and  of  eclampsia 
have  been  examined;  and  laboratory  studies  have  been 
made  of  the  brains,  suprarenals,  and  livers  of  many  animals 
into  which  had  been  injected  toxins  of  streptococci,  staphylo- 
cocci, colon  bacilli,  gonococci,  and  tetanus  bacilli;  of  animals 
to  which  had  been  given  intravenously  placental  extract, 
peptones,  leucin,  skatol,  extract  of  feces,  alien  blood-serum 
and  of  animals  in  anaphylactic  shock.     Without  exception 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


57 


• 

1 

1 

1 

C  D 

A.  Area  from  '■•■nil.  Hum;  normal  rabbit. 
I'.,   \n-.-i  from  cerebellum;  during  fright. 

C,  Area  from  oerebellum;  tax  hours  after  fright. 

D,  Area  from  cerebellum;  characteristic  changes  in  Purkinje  cells  in  fright. 

In.    II      Changes  Seen  in  Brain-cellb  oi  \  Rabbit  Subjected  to  Psab. 


THE    HISTOLOGIC    PATHOLOGY    OF    SH<  M   K 


59 


--^■Z.         M 


E  -  —  >■ 
—  ~z  -j.— 

£  a»«~  Pi 

Q 

^=7; 

3 
J 

She 
n  o  a 

~ 

:~  M 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


61 


ri 


q  ; 


%*& 


J 


Fio.  L3        \i:i   I   i  ROW  (  'l  Rl  Bl  i.i.i  M 

I  >i  i. inn  m    Tri  mi  nb      Show  ing 

l  i  i  i  i  i  us  I'.it  \i\-(  i  ii  -  "i  Con- 

i  i\i  M>    Si  i\ii  \.\  \\i>\     \\  1 1  ii      \i 
I  ■  IHI  I] 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


63 


»     Ja      8-5  2    fc 


til 

^  -  — 

'S'3'"' 

01    ID    ° 

--  = 


-  -  s 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


65 


.-.<■■ 

m 

- 
■v- 

.■           ■ 

•.; 

■ 
■ 

■ 

•• 

• 

-> 

2 

l":    ' 

Cells  from  normal  cerebellum      Cells  from  cerebellum    Cells   from    cerebellum, 
showing   the  muni-      showing  the  late  results 

(bate  results  of  in- 
jection of  skatol. 
Note-  tin-  hyperchro- 
matism. 

I.i  iii  i  us-   llii  us-n.LLs  of  Skatol  Ixjkction. 


nf  injection  of  skatol. 
Note    the    ohromatol- 

ysis. 


hrtir*h 


T 

.  i0e<    ,Sk«t.>'5oluT-H») 


Cannon  V  trating  the  increased  output  "t  adn  nalin  after 

inject  ion  "i  skatol. 

I .-,,.   is      Activation  01  Kinetic  System  Caused  bt  Injection  of  Skatoi 
'I'm  -i   Illustrations  Indicate  the  Explanation  oi    nn   General  Ex« 
mm  9tion  Shown  in  Cases  01    \\  [©-intoxication. 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK  67 

the  cells  of  the  brain,  the  suprarenals,  and  the  liver  showed 
precisely  the  same  changes  as  were  seen  under  traumatic 
injury,  and  emotional  injury — first  a  stage  of  hyperchro- 
matism,  followed  by  a  stage  of  chromatolysis  and — in  a 
small  percentage — a  final  stage  of  disintegration  (Fig.  13). 
Of  special  interest  is  the  fact  that  these  various  toxins  and 
foreign  proteids  as  well  as  anaphylaxis  and  placental  extract 
produced  a  large  increase  in  adrenalin  output  (Figs.  14 
and  15).  But  these  agents  caused  no  increased  output  of 
adrenalin  under  the  following  conditions:  if  the  nerve 
supply  of  the  suprarenals  had  been  first  divided;  if  the 
blood-vessels  supplying  the  suprarenals  had  been  first 
clamped;  or  if  the  suprarenals  had  been  excised  (Fig.  16). 

DRUGS     ANESTHETICS,  NARCOTICS,  AND  STIMULANTS 

Many  histologic  examinations  of  the  brain-cells  and  ob- 
servations of  the  adrenalin  output  by  Cannon's  method  were 
made  after  the  administration  of  ether,  urethane,  nitrous 
oxid,  and  morphin.  None  of  these  caused  either  brain-cell 
changes  or  increased  adrenalin  output  excepting  ether 
during  the  stage  of  excitement. 

Here  again  it  is  of  especial  significance  to  Dote  thai  under 
heavy  morphin  dosage  there  was  no  especial  change  in  the 
cells  of  the  brain,  the  Buprarenals,  and  the  liver  and  do  in- 
creased output  of  adrenalin  as  a  result  of  anaphylaxis,  or 

of  llie  Intravenous  injection  of  toxins  or  of  foreign  proteids 
(Fig.  17).  It  was  found  also  that  the  in>rm<il  output  of 
adrenalin  was  diminished  by  morphin.  Strychnin,  on  the 
other  hand,  caused  Cell  changes  of  precisely  the  same  type 

as  did  the  emotions,  toxins,  and  foreign  proteids;  that  is, 
;it  firsl  hyperchromatism  and  later  chromatolysis;   and  there 


68  ANOCI-ASSOCIATION 

was  also  increased  adrenalin  output.  Previous  division 
of  the  suprarenal  nerve-supply  prevented  the  increased 
output  of  adrenalin,  whatever  the  form  of  excitation. 

These  experimental  results  may  be  summarized  as  fol- 
lows:— All  the  above  mentioned  agents  that  caused  the  ac- 
tivation of  the  kinetic  system,  whether  emotional,  toxic,  for- 
eign proteid,  or  drug,  produced  identical  changes  in  the  cells 
of  the  brain,  the  suprarenals,  and  the  liver  and  also  increased 
the  adrenalin  output.  On  the  other  hand,  the  anesthetics  and 
the  narcotics  caused  neither  notable  brain-cell  changes  nor 
increased  adrenalin  output,  while  strychnin  caused  both. 

ANEMIA 

The  loss  of  blood  from  any  cause,  if  it  be  sufficient  to 
cause  a  low  blood-pressure  and  if  it  be  continued  long 
enough,  will  cause  deteriorating  changes  in  the  brain-cells. 

If  the  hemorrhage  be  continued  long  enough  and  the 
blood-pressure  be  low  enough,  some  brain-cells  will  be  perma- 
nently lost,  hence  in  cases  of  critical  hemorrhage  certain — 
perhaps  only  a  few — brain-cells  are  permanently  lost. 

It  might  be  supposed  that  the  brain-cell  changes  found 
in  cases  of  surgical  shock  are  entirely  due  to  low  blood- 
pressure.  That  a  low  blood-pressure  is  an  important  fac- 
tor is  unquestionable  in  the  light  of  our  brain-cell  studies, 
but  that  it  is  not  the  only  factor  is  proved  by  the  following 
experiment : 

The  blood-vessels  of  two  animals  were  anastomosed,  and 
as  the  blood-pressure  in  the  traumatized  animal  began  to 
fall,  fresh  blood  was  added,  so  that  during  the  entire  seance 
of  shock  trauma  the  blood-pressure  was  maintained  at  the 
normal  level.  Specimens  of  the  brain  were  removed  from 
the  living  animal  and  brain-cell  changes  were  found,  but  it 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


69 


5"  *>V     /i/evJjsdL' 


DHL 


^^sutvr^  w^i^  ic*J^- 


Control  teat;    no  adrenalin  pres- 
ent. 


Peptone  teal  negative  because  the  adrenal  elands  have 
been  removed  and  nenoe  no  adrenalin  oould  \«-  thrown 
into  the  circulation,  aa  il  would  nave  been  it  stimulated 
by  t > i ■  -  peptone.     I  In-  shows  thai  adrenalin  and  not  pep- 

i our  <:i n~.-  inhibition. 


Fi<;.  Hi.    Cannon  Test  fob  Adrenalin,  showing  Lack  <>r  Rba<  non   ro  Srni- 
dlatiom  \mi. if  Removal  of  Suprarenal.     (Compare  with  Fig.  14. 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


Brain-cells   from  dog  after  ana- 
phylaxis, wil  tn >u!  tnorphin. 


Brain-oells  from  dog  after  ana- 
phylaxis with  morphin,  ahowing 
protective  effect  "i  heavy  mor- 
phin doc 


Fio.  17. 


-Comparison  01    phe  Brainh  ell  Changes  Prodi  i  i  d  bi    \wrnv- 
i.wh  Alone  \\i>  i  Mm;  1 1 1  w  i  Morphin  Dosage. 


THE    HISTOLOGIC    PATHOLOGY   OF   SHOCK 


73 


required  much  more  trauma  to  produce  brain-cell  changes  in 
animals  whose  blood-pressure  was  kept  at  the  normal  h  w  /  than 
in  the  animals  whose  blood-pressure  was  allowed  to  take  its 

downward  course. 

ARE    THE     CELL    CHANGES     SEEN    IN    SHOCK     DUE    TO    THE 

PRODUCTS  OF  PATHOLOGIC  METABOLISM  OR  TO 

ALTERED  GASES  IN  THE  BLOOD? 

Thus  far  we  have  described  various  causes  which  injure 
the  cells  of  the  brain,  the  suprarenals,  and  the  liver  and  con- 


Fia.  Is.     Diagram  Showing   Anastomosis  oi    raa  Ciw  i  i  ition  oi    l>"'.   \ 

\Mi     I  ><>(,     I'.. 


tribute  in  varying  degrees  to  the  causation  <>i  surgical  shock. 
We  will  now  introduce  evidence  thai  the  principal  cause  of 
these  «'"'ll  changes  is  not  any  gaseous  change  in  the  blood  nor 
any  noxious  products  <>f  metabolism  resulting  from  the 
trauma. 


74  ANOCI-ASSOCIATION 

If  the  kinetic  theory  of  shock  be  correct,  then,  if  the  circu- 
lation of  two  dogs  be  so  anastomosed  that  their  blood  streams 
intermingle  freely,  and  if  only  one  animal  be  traumatized, 
the  functional  impairment  and  the  brain-cell  changes  will  be 
limited  to  the  animal  which  receives  the  injury.  On  the 
other  hand,  if  shock  be  due  to  the  altered  composition  of 
the  blood  whereby  the  brain-cells  are  affected  secondarily, 
then  both  dogs  will  suffer  equally  and  the  brain-cells  of  both 
will  show  like  signs  of  deterioration.  To  test  this  crucial 
point,  the  following  experiment  was  performed: 

The  proximal  end  of  one  carotid  artery  of  Dog  A  was  anas- 
tomosed with  the  distal  end  of  the  corresponding  carotid 
artery  of  Dog  B  (Fig.  18)  and  one  jugular  vein  of  Dog  A  was 
then  anastomosed  with  the  corresponding  vein  of  Dog  B 
so  that  the  blood  streams  of  both  animals  intermingled  with 
entire  freedom  and  in  large  volume.  The  dogs  were  ap- 
proximately of  equal  weight  and  physical  condition.  For 
two  hours  Dog  A  was  traumatized.  The  animals  were 
killed  simultaneously,  and  their  brain-cells  were  studied  by 
parallel  technique.  The  examination  showed  brain-cell 
changes — typical  shock  changes — only  in  Dog  A,  the  dog 
whose  body  had  been  traumatized,  and  no  brain-cell  changes 
in  Dog  B  (Fig.  19)  whose  body  had  not  been  traumatized, 
but  through  whose  brain  the  blood  of  the  traumatized  dog 
flowed  freely  during  the  two  hours.  This  result  strongly 
supports  the  kinetic  theory,  and  with  equal  strength  opposes 
any  theory  which  implies  that  gaseous  changes  in  the  blood 
or  the  formation  of  noxious  products  are  the  leading  cause 
of  the  brain-cell  changes,  though  undoubtedly  they  are  a 
secondary  cause. 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


i  •) 


_. .   .     .. 

• 

• 

4 

•>». 

I 

' 

. 

.     *' 

vd.   \ 

• 

lir.ii n  hi  untraumatised  dog  ■>■  Brain  of  traumatised  d 

I  I'.    19.    Symbiotu    Shock.     Experiment.    The  Cerebellum   prom  the 

I    ^TRAUMATIZED     I  >' "  •       R.ECIPIEN1        wi>     PROM     im.     TRAUMATIZE^     I'"'. 
I  )n- 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK 


77 


THE  INFLUENCE  OF  THE  INHALATION  ANESTHETICS  UPON 
SHOCK -PRODUCTION 

On  our  theory  that  the  morphologic  changes  in  the  brain- 
cells  are  produced  by  the  conversion  of  potential  into  kinetic 
energy,  and  that  in  this  conversion  of  potential  energy  into 
kinetic  energy  oxygen  is  a  necessary  factor,  one  would  ex- 
pect to  find  that  a  given  amount  of  trauma  under  an  an- 
oxyemic   anesthetic    like    nitrous-oxid-oxygen   would    pro- 


7o 

ID 

10 

30 

14-0 

70 

GO 

TO 

80 

90 

Active. 

S3 

hei 

"n'JtToluis 

0* 

L 

TlaTTn 

LI. 

F^tiSaedb. 

"Ether 

rA-o'xs 

0*i 

I 

JBl 

TTT 

E%h  a.  listed. 

Ei 

hei 

■» 

; 

tTO 

as 

Ox' 

L 

>  - 

Tim 

Jul. 

Flo.   20.     Differential   Purkinje  Cell  Counts.    Comparison   of    ran 
Effects  oi  Shock  under  Ktmku  Anesthesia  wi>  i  ndeb  Nitroi  B-Oxn>- 

<  bn  '.in  Am  -mi  >i  \. 

duoe  less  change  than  an  equal  amounl  of  trauma  in  an  ani- 
mal  under  ether;  for  nitrous  oxid,  unlike  ft  her,  owes  its  an- 
esthetic property  to  its  interference  with  the  use  of  oxygen 
by  the  brain-cells.  Testing  this  point  experimentally,  we 
found  that  under  approximately  equal  trauma  the  changes 
in  the  brain-cells  were  approximately  three  times  as  greal 
under  ether  anesthesia  as  under  oitrous-oxid-oxygeD  anes- 
thesia (Fig.  20);  thai    the  fall   in  the  blood-pressure  was 


78 


ANOCI-ASSOCIATION 


on  the  average  two  and  a  half  times  greater  under  ether  than 
under  nitrous-oxid-oxygen;  and  finally,  that  the  condition  of 
the  animal  was  worse  after  trauma  under  ether  than  after 
equal  trauma  under  nitrous-oxid-oxygen.    In  the  course  of 


Co mpo  s//e  /T3-  c /  n<p s. 

no 

j'/C 
/oa 

9o 

80 
7o 
60 
5o 
4o 
Jo 

to 

0 

4v,„f£  n.n.,1 

/,,,,..._ 

.-.?/....,  **..„^ 

s-u-  *«-.. 

2*^,.*««~ 

*-  ft— 

VV'1' 

- 

\^5 

^\ 

Fig.  21. — Chart  Compiled  from  Laboratory  Experiments  Illustrating 
the  Protective  Effect  of  Nitrous-Oxid-Oxygen  Anesthesia  in  Cases 
of  Shock,  as  Evidenced  by  the  Maintenance  of  the  Blood-pressure. 


operations  on  the  human  body  one  observes  constantly  the 
protective  effect  of  nitrous-oxid-oxygen  anesthesia.  This, 
however,  is  what  one  should  expect  if  the  kinetic  theory 
of  shock  be  true  (Fig.  21). 

Then,  too,  the  mere  excitation  due  to  the  feeling  of  suffo- 


THE    HISTOLOGIC    PATHOLOGY    OF    SHOCK  7l.» 

cation  while  inhaling  ether  causes  a  certain  amount  of  ex- 
haustion from  which  the  patient  taking  nitrous-oxid-oxygen 
is  spared. 

We  may  conclude,  therefore,  that  while  the  brain-cell 
changes  resulting  from  a  surgical  operation  are  not  due  to 
the  inhalation  anesthetic  per  se,  yet  their  extent  is  to  a 
considerable  degree  determined  by  the  anesthetic  which 
is  used.  As  these  changes  are  less  marked  under  nitrous- 
oxid-oxygen  than  under  ether,  the  former  should  be  the  in- 
halation anesthetic  of  choice. 


CHAPTER  III 
THE  CLINICAL  PATHOLOGY  OF  SHOCK 

Shock-Producing  Effect  of  Stimulation  of  the  Contact  Ceptors.  Comparative 
Shock-Producing  Effects  of  Traumata  of  Different  Parts  of  the  Body.  Com- 
parative Effects  of  Different  Types  of  Trauma.  Specificity  of  Nerve-Muscular 
Response  to  Adequate  Stimulation.  Shock-Producing  Effect  of  Stimulation 
of  the  Distance  Ceptors — the  Emotions,  Especially  Fear. 

SHOCK-PRODUCING    EFFECT    OF     STIMULATION     OF     CONTACT 

CEPTORS 

The  clinical  clue  to  the  cause  of  the  discharge  of  energy 
in  a  surgical  operation,  with  the  consequent  physiologic  ex- 
haustion and  morphologic  changes  in  the  brain,  the  supra- 
renals,  and  the  liver,  was  given  by  the  observation  of  the 
behavior  of  animals  under  deep  and  under  light  anesthesia 
during  the  infliction  of  physical  injury.  Under  surgical 
anesthesia,  rough  handling  of  the  tissues  is  usually  accom- 
panied by  a  marked  increase  in  the  respiratory  rate  and  an 
alteration  in  blood-pressure. 

Muscular  response  to  trauma  under  inhalation  anesthesia 
may  be  only  purposeless  moving,  but  if  the  anesthesia  be 
sufficiently  light  and  the  trauma  be  sufficiently  strong, 
movements — unmistakably  purposive — may  be  produced. 
To  injury  under  inhalation  anesthesia  every  grade  of  re- 
sponse may  be  seen,  varying  from  the  slightest  change  in  res- 
piration or  in  blood-pressure  to  a  vigorous  defensive  struggle. 
As  to  the  purpose  of  these  subconscious  movements,  there 
can  be  no  doubt — they  are  efforts  to  escape  from  injury. 
The  respiratory  centers  and  the  circulatory  centers  are  doing 
their  part  in  crying  out — in  trying  to  effect  escape.  So,  too, 
all  the  rest  of  the  brain-cells  are  doing  their  part  by  stimu- 

80 


THE    CLINICAL   PATHOLOGY    OF    SHOCK  81 

lating  the  motor  mechanism  for  defense  or  escape,  but,  be- 
cause of  the  anesthetic  paralysis,  the  voluntary  muscles  can- 
not express  themselves.  Were  it  not  for  the  muscular  par- 
alysis, the  patient's  face  would,  without  doubt,  express 
motor  activity  as  strongly  as  it  is  expressed  in  the  accom- 
panying picture  of  the  athlete  whose  motor  mechanism  is 
driven  by  voluntary  impulses  only  (Fig.  22).  The  motor 
mechanism  of  a  patient  under  inhalation  anesthesia  may  be 
driven  even  more  powerfully,  though  in  silence,  throughout 
the  course  of  a  surgical  operation. 

The  result  is  the  same  as  it  would  be  if  a  major  surgical 
operation  were  to  be  performed  under  curare  alone.  Curare 
completely  paralyzes  all  voluntary  muscles,  but  produces  no 
anesthesia.  It  therefore  gives  complete  muscular  relaxa- 
tion— a  dead  paralysis  that  would  satisfy  the  roughest  sur- 
geon. During  such  an  operation  there  would  be  absolute 
stillness,  but  after  the  paralyzing  effect  of  the  curare  had 
worn  off  and  the  patient  had  again  become  able  t<>  express 
himself,  whal  would  he  say?  What  would  the  surgeon  think'.' 
Yet  the  surgeon  daily  inflicts  equally  greal  injury  upon  the 
brain  of  the  anesthetized  patient.  For  tin-  reason  a  pa- 
tient who  enter-  the  operating  room  in  the  flood  of  health 
and  with  composed  face  may  emerge  broken  and  shattered 
and  with  the  facies  of  the  tortured  from  ;i  severe,  perhaps 
rough,  operation  under  inhalation  anesthesia. 

COMPAPATIVE  SHOCK-PFODUCING  EFFECTS  OF  TRAUMATA  OF 
DIFFERENT  PARTS  OF  THE  BODY 

It   i-  Significant   that   the  facility  with  which  shock  may  be 

produced   depend-   upon    the   part    of  the   body   injured   and 

upon    the   type   of   trauma    to   which    the   pari    is  subjected. 

We  have  stated  that  shock  is  the  resull  of  brain-cell  exhaus- 


82  ANOCI-ASSOCIATION 

tion  caused  by  powerful  or  frequently  repeated  stimuli  re- 
ceived through  the  nerve  ceptors.  We  should  then  expect 
that  the  greatest  brain-cell  exhaustion  and  consequent  shock 
would  result  from  injuries  to  those  parts  of  the  body  most 
richly  supplied  with  nociceptors. 

We  have  stated  also  that  the  nociceptors  are  most  abun- 
dant in  those  parts  of  the  body  which,  in  the  course  of  evo- 
lution, have  most  frequently  been  subjected  to  injuring  con- 
tacts with  environment.  That  is,  the  nociceptors  are  a 
part  of  the  mechanism  for  self-defense  which  during  the  ages 
of  evolution  has  been  gradually  developed  for  the  preserva- 
tion of  the  individual  and  consequently  of  the  race. 

On  this  basis  the  hands  and  feet,  and  the  trunk,  should 
have  many  nociceptors,  while  the  brain,  which  through 
probably  the  greater  part  of  man's  evolution  has  been  pro- 
tected by  a  skull,  should  have  none.  The  first  premise 
needs  no  experimental  proof — daily  experience  is  sufficient 
to  prove  to  every  one  the  rich  endowment  of  the  exposed 
portions  of  the  body  with  these  warning  nerve  guards.  As 
to  the  second  premise — it  is  known  clinically  that  even  in 
conscious  patients,  explorations  for  brain  tumors  with  a 
probe  elicit  neither  pain  nor  any  evidence  of  altered  physio- 
logic functions.  Realizing,  however,  the  importance  of  con- 
clusive proof  of  the  fact  that  the  brain  possesses  no  noci- 
ceptors, a  series  of  careful  experiments  were  made.  The 
cerebral  hemispheres  of  dogs  were  exposed  by  the  removal  of 
the  skull  and  dura  under  ether  and  local  anesthesia.  Then 
in  each  animal  one  entire  hemisphere  was  slowly  but  com- 
pletely destroyed,  either  by  rubbing  it  with  a  piece  of  gauze 
or  by  burning.  In  no  instance  was  there  more  than  a  slight 
response  of  the  centers  governing  the  circulation  and  res- 


THE    CLINICAL    PATHOLOGY    OF    SHO<  K 


v; 


Fro.  22. 


A'liii.i.M       \> ii    Activation  01    sis   Motob  Mechanism   \- 

Portrayed  in  his  Facial  Expression, 


THE    CLINICAL    PATHOLOGY    OF    SHOCK  85 

piration  and  no  morphologic  change  was  noted  in  the  brain- 
cells  of  tin  uninjured  hemispheres.  Collapse  from  inter- 
ference with  the  medullary  centers  is  not,  of  course,  true 
surgical  shock. 

We  must  conclude,  therefore,  that  the  brain  contains 
no  mechanism — no  nociceptors— the  dired  stimulation  of 
which  causes  a  discharge  of  nervous  energy  in  a  self-defensive 
action.  That  is.  direct  injury  of  the  brain  can  cause  no 
purposeful  nerve-muscular  action,  while  direct  injury  of  the 
hand,  for  example,  due-  cause  purposeful  nerve-muscular 
action.  In  like  manner  the  deeper  portions  of  the  spinal 
region,  the  lungs,  and  parts  protected  within  the  thoracic 
cavity,  have  been  sheltered  from  trauma,  and  they  show  but 
little  power  of  causing  ;i  discharge  of  nervous  energy  in  re- 
sponse to  injury.  Since,  in  the  harsh  period  of  man's  evo- 
lution, injury  to  the  heart,  the  brain,  and  the  Lungs  led  to 
immediate  fatal  results,  there  was  no  opportunity  through 
natural  .-election  for  the  development  of  a  protective  mus- 
cular reaction.  These  parts  of  necessity,  therefore,  were 
placed  under  special  structural  protection.  On  the  other 
hand,  injuries  of  the  abdomen  and  of  the  chesl  cause  intense 
discharges  of  nervous  energy  these  regions  standing  first 
in  their  capability  for  Bhock-production. 

\'  \t  in  order  follow  the  extremities,  the  neck,  and  the 
back.      In   the  extremities   fche   30le  and    the  palm  are  more 

susceptible  to  shock-producing  injury  than  are  the  dorsa; 

within   the  abdomen,   the   region  of  the  diaphragm   is   more 

susceptible  than  thai  of  the  pelvis;  the  kidneys,  the  ureters, 
and  the  urinary  bladder  have  a  relatively  low  shock-produc- 
ing value,  while  the  omentum  is  practically  a  negative  tis- 
sue. As  one  would  expect,  however,  injuries  t"  tin1  periph- 
eral nerve  trunk-  produce  intense  -hock. 


86  ANOCI-ASSOCIATION 

COMPARATIVE     SHOCK-PRODUCING     EFFECTS     OF      DIFFERENT 
TYPES  OF  TRAUMA 

Not  only  is  the  degree  of  shock  dependent  upon  the  part 
of  the  body  injured,  but  it  varies  also  with  the  type  of  trauma 
inflicted.  Powerful  response  is  made  to  crushing  injuries 
by  environmental  forces;  to  such  injuring  contacts  as  re- 
semble the  impacts  of  fighting;  to  such  tearing  injuries  as 
resemble  those  made  by  teeth  and  claws.  That  is,  injuries 
which  resemble  those  inflicted  by  physical  environment  or 
by  the  carnivora  in  fighting  each  other  and  in  killing  their 
prey  are  the  most  efficient  shock-producing  traumata  that 
are  known. 

As  a  significant  corollary  to  these  observations  we  must 
note  that  there  is  no  nerve-muscular  response — and  conse- 
quently no  shock — as  a  result  of  injuries  inflicted  by  forces 
which  are  of  such  late  development  that  they  played  no 
part  in  evolutionary  history.  For  example,  heat  is  a  stim- 
ulus which  has  existed  since  the  days  of  prehistoric  man, 
while  the  a>ray  is  a  discovery  of  to-day.  Every  one  knows 
the  intense  shock  produced  by  burns  with  fire,  while  the 
x-ray  may  injure  the  bodily  tissues  to  the  point  of  their 
destruction  even  without  producing  shock.  There  was  no 
weapon  in  the  prehistoric  ages  which  could  move  at  the 
speed  of  a  bullet  from  a  modern  rifle;  therefore,  while  slow 
penetration  of  the  tissues  produces  great  pain  and  muscular 
response,  with  consequent  exhaustion,  there  is  slight,  if  any, 
response  to  the  swiftly  moving  bullet — the  only  obvious  de- 
fense against  such  injury  is  strategy.  For  the  same  reason, 
the  sharp  division  of  tissues  by  cutting  produces  less  re- 
sponse than  blunt  injury;  indeed,  one  might  imagine  that  the 
body  could  be  cut  to  pieces  by  a  superlatively  sharp  knife  ap- 


THE    CLINICAL    PATHOLOGY    OF    SHOCK  87 

plied  at  lightning  speed  without  material  nerve-muscular  re- 
sponse— hence  without  shock. 

On  this  phylogenetic  premise  also  we  should  at  once  con- 
clude that  there  are  no  nociceptors  for  heat  within  the  ab- 
domen, because  during  countless  years  of  evolution  the 
intra-abdominal  region  never  came  into  contact  with  heat. 
That  this  inference  is  correct  is  shown  by  the  fact  that  the 
application  of  a  thermo-cautery  to  the  intestines  when  com- 
pleting a  colostomy  in  a  conscious  patient  is  absolutely 
painless. 

On  the  other  hand,  just  as  the  outer  portions  of  the  body 
—the  skin,  the  ear,  the  nose,  the  sole  of  the  foot,  etc. — have 
developed  the  specific  types  of  nociceptors  best  adapted  for 
their  specific  protective  purposes,  so  the  abdominal  viscera 
have  developed  equally  specific  nociceptors  as  a  protection 
against  nocuous  influences.  We  must  believe  thai  there  has 
always  been  the  danger  of  perforations  from  ulcers  in  the  gas- 
trointestinal tract;  of  infections  following  tearing  injuries 
from  without;  of  appendicitis;  of  gall-stone-;  of  peritonitis 
from  various  causes;  and  of  overdistention  of  the  hollow 
viscera  from  various  forms  of  obstruction.  So  we  find  that 
while  the  division  of  tin'  intestines  with  ;i  sharp  knife  causes 
no  pain  and  consequently  no  Derve-muscular  response,  pull- 
ing on  the  mesentery  does  elicit  pain  ami  protective  response 
because  Buch  pulling  resembles  ih<  pulling  of  distention. 
Ligation  of  the  Btumpof  the  appendix  causes  Bharp, cramp- 
like pain;  distention  of  the  gall-bladder  and  of  the  intes- 
tines causes  pain;  and  nil  these  conditions  may  be  accom- 
panied by  pros!  ral  i"ii  and  exhaust  ion. 

In  the  course  of  abdominal  operations,  rough  manipula- 
tion of  the  parietal  peritoneum  often  causes  :i  marked  in- 


55  ANOCI-ASSOCIATION 

crease  in  the  respiratory  rate,  especially  in  the  expiratory 
force.  Under  light  anesthesia  severe  manipulation  of  the 
peritoneum  often  causes  such  vigorous  contractions  of  the 
abdominal  muscles  that  the  operator  is  greatly  hindered  in 
his  work. 

As  to  the  reason  for  these  subconscious  movements,  there 
can  be  no  doubt, — they  are  efforts  to  escape  from  injury. 
Pain,  wherever  or  however  produced,  or  manipulations  and 
injuries,  which,  in  a  conscious  person,  would  cause  pain,  are 
invariably  a  stimulation  to  motor  activity,  whose  ultimate 
object  is  protection.  Thus  by  the  muscular  action  result- 
ing from  pain  we  are  protected  against  heat  and  cold; 
against  too  intense  light;  against  local  anemia  caused  by 
prolonged  pressure  upon  any  portion  of  the  body.  So,  too, 
pain  of  greater  or  less  intensity  compels  the  required  emp- 
tying of  the  pregnant  uterus,  and  the  evacuation  of  the  in- 
testine and  of  the  urinary  bladder. 

As  muscular  activity  is  always  the  result  of  discharges  of 
brain-cell  energy,  brain-cell  exhaustion  in  varying  degrees 
must  be  the  inevitable  sequence  of  pain.  Even  if  the  re- 
sultant muscular  activity  be  prevented,  the  pain  stimuli 
still  bear  their  message  to  the  brain  and  the  brain  responds, 
to  receive  again  new  and  more  powerful  stimuli  from  the 
parts  to  which  helpful  activity  is  denied. 

SPECIFICITY    OF    NERVE-MUSCULAR    RESPONSE    TO    ADEQUATE 

STIMULATION 

It  should  be  noted  that  in  every  instance  the  muscular 
activity  resulting  from  pain  is  specific  in  its  type,  its  dis- 
tribution, and  its  intensity.  This  specificity  is  true  not  only 
of  pain  which  is  the  result  of  external  stimulation,  but  is 
true  also  of  the  pain  associated  with  certain  types  of  infec- 


THE    CLINICAL    PATHOLOGY    OF    SHOCK  89 

tions.  The  infections  which  are  associated  with  pain  are 
those  in  which  the  danger  may  be  spread  by  muscular  ac- 
tion or  in  which  the  fixation  of  parts  by  continued  muscular 
rigidity  is  an  advantage.  As  a  striking  corollary  to  this  fact 
we  find  that  the  type  of  infection  which  may  cause  muscular 
action  when  it  attacks  one  region  of  the  body,  causes  no 
such  action  when  it  attacks  another  region.  On  the  con- 
trary, in  the  case  of  the  painless  exanthemata,  the  protec- 
tive response  is  not  motor  but  chemical.  That  is,  in  the 
case  of  the  painless  infections,  the  defense  is  by  the  forma- 
tion of  immune  bodies  in  the  blood.  In  the  case  of  the  pain- 
ful pyogenic  infections,  the  defense  is  phagocytic.  In  these 
cases  the  parts  of  the  body  not  invaded  must  be  protected, 
and  this  protection  is  secured  by  various  forms  of  motor 
activity.  First,  large  quantities  of  lymph  are  poured  out; 
second,  the  part  is  fixed  by  continuous  contraction  of  the 
neighboring  muscles;  third,  those  muscles  are  inhibited 
which  by  their  ordinary  action  would  spread  the  infection; 
and  wherever  there  is  protective  muscular  rigidity,  there  is 
also  pain. 
In  all  these  infections  the  accompanying  exhaustion 

-hock      is  in  proportion  to  the  muscular  activity  excited  in 

response  to  the  pain  stimuli.  This  postulate  is  substan- 
tiated by  the  brain-cell  findings  in  persons  who  have  died 
a-  ,i  result  of  pyogenic  infections  and  in  animal-  which  have 
been  inoculated  with  various  pyogenic  organisms.  To  the 
extent  that  the  1  nain-cells  are  damaged  by  infection,  the 
pat ient 'g  margin  "t  safety  is  reduced. 

We  mii-t  observe  also  as  a  further  proof  of  our  hypothesis 
that  no  muscular  rigidity  and  consequently  no  pain  is  pro- 
duced by  pyogenic  infections  in  those  organs  whose  muscu- 


90  ANOCI-ASSOCIATION 

lar  contraction  can  in  no  way  assist  in  localizing  the  infec- 
tion. This  is  true  of  pyogenic  infections  in  the  substance 
of  the  liver;  in  the  parenchyma  of  the  kidney;  within  the 
brain;  in  the  retro-peritoneal  space;  in  the  lobes  of  the 
lung;  in  the  chambers  of  the  heart;  in  the  blood  vessels  of 
the  chest  and  abdomen. 

The  peritoneum  in  its  relation  to  vast  fields  of  possible 
infection  has  through  the  law  of  natural  selection  been  won- 
derfully endowed  with  the  means  of  resisting  and  overcom- 
ing infection.  If  the  focus  can  be  localized,  almost  any  in- 
fection can  be  overcome  by  the  peritoneum.  This  localiza- 
tion is  accomplished  by  holding  the  muscular  abdominal 
wall  still  and  rigid;  by  holding  the  muscular  intestinal  wall 
still  and  rigid  against  a  large  volume  of  gas ;  and  by  quickly 
throwing  out  a  fixative  fluid — or  exudation.  As  a  secondary 
adaptation  the  stomach  contents  are  ejected  by  vomiting 
so  that  a  protective  anorexia  against  useless  food  is  an  added 
guard.  Any  perforation  of  the  intestine  awakens  this  great 
anti-infective  adaptive  motor  activity.  Every  entrance  to 
the  abdominal  cavity  will  awaken  to  some  degree  this  pro- 
tective muscular  action,  since  the  accidental  openings  by 
the  forces  of  environment  in  the  past  must  have  been  fol- 
lowed nearly  always  by  pyogenic  invasion. 

If  these  conclusions  are  correct,  why  are  certain  cases, 
familiar  to  every  surgeon,  of  wide-spread  general  peritonitis, 
or  of  cholecystitis,  or  of  other  abdominal  lesions  unaccom- 
panied by  pain,  often  without  muscular  rigidity  or  tender- 
ness even,  so  that  the  surgeon  may  be  misled,  and  the  re- 
sult may  be  fatal?  Such  patients  are  almost  invariably 
found  among  the  aged  or  the  very  young,  and  their  exist- 
ence is  but  a  further  proof  of  our  hypothesis. 


THE    CLINICAL    PATHOLOGY    OF    SHOCK  91 

The  reason  why  there  is  no  pain  in  the  aged  or  in  the  very 
young  is  because  in  senility  the  brain  is  so  deteriorated,  and 
in  infancy  it  is  so  undeveloped  that  the  cerebral  mechanism 
of  associative  memory  is  inactive;  hence  pain  and  tender- 
ness, which  are  among  the  oldest  of  the  associations,  are 
lacking.  This  same  principle — the  loss  or  obliteration  of 
associative  memory — underlies  the  freedom  from  pain  in  the 
patient  under  the  influence  of  narcotics  and  anesthetics. 
Hence  it  is,  that  in  the  extremes  of  life,  the  diagnosis  of  in- 
jury and  disease  is  beset  by  special  difficulties,  the  entire 
body  becoming  as  silent  as  are  the  brain,  the  pericardium 
and  the  other  symptomless  areas. 

It  is  plain  from  these  premises  that  the  discharge  of  en- 
ergy caused  by  an  adequate  mechanical  stimulation  of  the 
nociceptors  is  best  explained  by  the  laws  of  evolution  and 
association.  Thai  is,  injuries  awaken  such  reflex  actions 
;i-  have  been  developed  by  natural  selection  for  the  purpose 
of  self-protection.  Adequate  stimulation  of  the  nocicep- 
tors for  pain,  however,  is  not  the  only  means  of  causing  a 
discharge  of  nervous  energy.  Vast  amounts  of  energy  are 
discharged  as  a  result  of  the  gentlest  stimulation  of  the  so- 
called  ticklish  areas  of  the  body.  The  resultant  motor  ac- 
tivity in  such  a  case  is  a  self-protective  action  evolved  for 
the  purpose  of  guarding  delicate  areas  from  gentle  contacts 
which  might  be  the  precursors  of  serious  injury  in  most  im- 
portant regions  of  the  body.  The  ear  in  man  and  in  ani- 
mals i>  acutely  ticklish  the  adequate  stimulus  being  any 
foreign  body,  but  especially  an  insect-like  contact.  The 
discharge  of  energy  and  consequent  motor  activity  in  horses 
and  in  cattle  on  adequate  stimulation  of  the  ticklish  recep- 
tors of  the  ear  is  so  extraordinary  that  we  inu-i  conclude 


92  ANOCI-ASSOCIATION 

that  in  the  course  of  evolution  such  activity  was  of  great 
importance  to  the  safety  of  the  animal.  A  similar  ticklish 
zone  guards  the  nasal  chambers;  here  the  resultant  activity 
is  sufficiently  powerful  to  dislodge  and  expel  the  foreign 
body  causing  the  ticklish  contact.  In  fact,  a  sudden  transi- 
tion from  darkness  to  intense  light  is  of  itself  sufficient  to 
cause  sneezing.  The  larynx  is  exquisitely  ticklish;  the  ex- 
hausting results  of  the  coughing  which  may  follow  even 
slight  laryngeal  stimulation  prove  how  powerful  has  been 
the  consequent  discharge  of  energy.  With  the  ticklish 
areas  might  be  classed  the  mouth  and  pharynx  which  pos- 
sess active  receptors  which  respond  so  powerfully  to  the 
presence  of  noxious  substances  that  violent  motor  activity 
is  excited  as  a  result  of  which  the  most  profound  exhaustion 
is  experienced.  Other  areas  which  are  capable  of  discharg- 
ing vast  amounts  of  energy  in  response  to  ticklish  contacts 
are  the  lateral  chest  walls,  the  abdomen,  the  loins,  the  neck, 
and  the  soles  of  the  feet.  Under  present  conditions  the 
motor  activity  resulting  from  ticklish  contacts  with  these 
regions  is  of  little  value  to  man,  excepting  perhaps  the  sole 
of  the  foot,  where  the  strong  muscular  response  which  is  the 
immediate  result  of  even  the  slightest  contact  often  is  the 
means  of  escape  from  a  painful  injury. 

Should  anyone  doubt  the  energy-producing  power  of  the 
ceptors  in  the  ticklish  regions  of  the  body,  let  him  be  bound 
hand  and  foot  and  then  tickled  for  an  hour.  He  would 
emerge  from  this  test  as  completely  exhausted  as  though  he 
had  experienced  a  major  surgical  operation  or  had  run  a 
Marathon  race.  Another  witness  to  the  exhausting  effects 
of  stimulation  on  one  of  the  sensitive  regions  is  the  testi- 
mony of  travellers  to  the  prostrating  results  of  the  infliction 


THE    CLINICAL    PATHOLOGY    OF    SHOCK  93 

of   the   bastinado,   one   of   the  most  painful   punishments 
known. 

Examples  of  specific  reaction  to  adequate  stimulation 
might  be  multiplied  indefinitely.  Enough  has  been  said, 
however,  to  show  that  in  the  course  of  evolution  certain 
portions  of  the  body  were  constantly  exposed  to  danger,  and 
that  as  a  consequence  a  special  mechanism  was  evolved  for 
their  adequate  defense.  This  mechanism  consists  of  nerve 
ceptors  to  receive  the  injurious  contact;  of  fibers  to  convey 
the  message  of  danger  to  the  brain;  of  a  store  of  energy  in 
the  cells  of  the  brain  which,  upon  the  receipt  of  an  adequate 
stimulus,  is  spontaneously  released  to  produce  a  protective 
muscular  activity.  The  truth  of  this  postulate  being 
granted,  it  becomes  evident  that  the  sum  total  of  brain-cell 
energy  must  be  diminished  by  each  stimulus,  and  it  follows 
as  a  self-evident  corollary  thai  the  brain-cell  energy  will  be 
mosl  greatly  diminished  by  injuring  contacts  with  those 
part-  of  the  body  most  richly  supplied  with  nociceptors. 
The  comparative  shock-producing  effect-  of  operations  upon 
different  portion-  of  the  body  are  thus  explained  and  in 
the  explanation  appeal's  prima facU  one  key  to  the  achieve- 
ment of  the  shockless  operation  the  use  in  these  shock- 
producing  regions  of  gentle  manipulations  ami  of  a  tech- 
nique which      ;i-  far  a-  possible      differs  from   the  force-  a- 

an  adaptation  to  meet  which  the  defensive  mechanism  was 
evolved. 

SHOCK-PRODUCING  EFFECT  OF  STIMULATION  OF  THE  DISTANCE 
CEPTORS     THE  EMOTIONS.  ESPECIALLY  FEAR 

\     self-preservation  is  the  most   deeply   rooted  instinct 
in  .ill  Living  beings     30  fear  is  the  most  widely  distributed 

of  the  emotion-,  and  thf  most  powerful  in  it-  effect  upon 


94  ANOCI-ASSOCIATION 

the  organism.  As  the  injured  body  tries  to  withdraw  from 
painful,  dangerous  contacts,  so  the  perception  of  threatened 
danger  causes  the  body  to  activate  itself  for  withdrawal. 
So  powerful  has  this  instinct  to  flee  from  anything  which  en- 
dangers the  safety  of  the  individual  become  that  distant 
dangers  even,  or  the  mere  memory  of  them,  may  cause  all 
the  phenomena  associated  with  the  activity  once  experi- 
enced by  the  individual  or  his  ancestors  when  escaping  from 
a  present  danger.  The  extreme  prostrating  effect  produced 
in  many  people  by  the  mere  sight  of  blood  can  be  explained 
only  on  this  phylogenetic  basis. 

In  rabbits  frightened  by  dogs,  but  not  injured  and  not 
chased,  the  principal  clinical  phenomena  are  rapid  heart, 
accelerated  respiration,  prostration,  tremors,  and  a  rise  in 
temperature.  The  dogs  show  similar  phenomena,  excepting 
that  instead  of  muscular  relaxation,  as  in  the  rabbits,  the 
dogs  show  aggressive  muscular  action.  Both  the  dogs  and 
the  rabbits  are  exhausted,  but  the  exhaustion  of  the  rabbits 
is  greater  even  though  the  dogs  may  exert  themselves  ac- 
tively and  the  rabbits  remain  physically  passive. 

The  analysis  of  the  phenomena  of  fear  shows  that,  as  far 
as  can  be  determined,  all  of  the  bodily  functions  which  are 
of  no  direct  assistance  in  the  effort  toward  self-preservation 
are  suspended.  In  a  voluntary  expenditure  of  muscular 
energy,  as  in  the  chase  or  in  athletic  exercises,  the  suspension 
of  the  other  bodily  functions  is  by  no  means  so  complete. 
Fear,  therefore,  and  above  all  fear  associated  with  trauma 
may  drain  the  dischargeable  nervous  energy  of  the  body  to 
the  lowest  depths  and  as  a  consequence,  produce  the  great- 
est possible  exhaustion,  even  to  the  point  of  death.  Not 
only  is  this  true,  but  fear  causes  a  low  brain  threshold  and, 


THE    CLINICAL    PATHOLOGY    OF    SHOCK  95 

therefore,  to  the  person  obsessed  by  fear,  all  stimuli — both 
physical  and  psychical — are  augmented. 

After  fear,  anger  is  probably  the  emotion  most  damaging 
in  its  effects  upon  the  body  mechanism.  Animals  which 
have  no  natural  weapons  for  attack  do  not  experience  anger, 
but  when  danger  threatens,  energize  the  muscles  to  be  used 
for  flight.  On  the  other  hand,  those  animals  which  possess 
weapons  of  defense  energize  these  muscles  for  attack  when 
in  the  presence  of  danger.  Man  partakes  of  the  nature  of 
both  the  fighting  and  the  fleeing  animals,  and  consequently 
fear  alone  may  possess  him,  or  anger  alone,  or  his  body  may 
be  shaken  by  the  combined  force  of  both  emotions.  A 
proof  of  the  phylogenetic  origin  of  anger  is  shown  by  the 
fact  that,  though  the  efficiency  of  the  hands  of  man  has 
largely  supplanted  the  use  of  the  teeth  as  defensive  weapon-. 
he  still  sets  his  jaw  and  shows  his  teeth  in  moments  of 
great  emotional  excitement. 

On  this  basis  the  disastrous  effects  of  worry  are  readily 
comprehended,  tor  worry  partakes  of  the  nature  of  both 
fear  and  anger.  It  is  a  chronic  state  of  attempt  to  escape 
from  Mime  threatening  evil  or  of  futile  efforts  to  combat  the 
cause  <>t  -"tin-  anticipated  disaster.  This  conception  ex- 
plain- many  bodily  impairments  and  diseases;  it  explains 
the  viciousness,  alternating  with  Bulkiness,  the  progressive 
weakness,  t<>  death  even,  shown  by  animals  in  captivity; 
it  explains  the  grave  digestive  and  metabolic  disturbances 
resulting  from  prolonged  financial  strain,  or  anxiety  for  one's 
self  or  others;  it  explain- 1  he  comprehensive  physical  changes 
that  are  wrought  by  sexual  love  and  hate;  it  shows  how  al- 
most any  factor  in  the  environment,  through  phylogenetic 
and  ontogenetic  associations,  may  influence  the  functions 


96  ANOCI-ASSOCIATION 

of  the  bodily  organs.  It  is  because,  in  the  uncompromising 
law  of  the  survival  of  the  fittest,  man  was  evolved  as  a  motor 
being,  that  each  of  his  organs  has  at  some  time  in  its  develop- 
ment served  in  the  relentless  struggle. 

On  this  mechanistic  basis  the  emotions  may  be  explained 
as  activations  of  the  entire  motor  mechanism  for  fighting, 
for  escaping,  for  copulating.  The  sight  of  an  enemy  stimu- 
lates in  the  brain  those  patterns  formed  by  the  previous 
experiences  of  the  individual  with  that  enemy,  and  also  the 
experiences  of  the  race  whenever  an  enemy  had  to  be  met 
and  overcome.  These  many  brain  patterns  in  turn  acti- 
vate each  that  part  of  the  body  through  which  lies  the  path 
of  its  own  adaptive  response — these  parts  including  the 
special  energizing  or  activating  organs. 

The  effect  of  the  emotions  upon  the  body  mechanism  may 
be  compared  to  that  produced  upon  the  mechanism  of  an 
automobile  if  its  engines  are  kept  running  at  full  speed  while 
the  machine  is  stationary.  The  whole  machine  will  be 
shaken  and  weakened,  the  batteries  and  weakest  parts  being 
the  first  to  become  impaired  and  destroyed,  the  length  of 
usefulness  of  the  automobile  being  correspondingly  limited. 

Since,  then,  deleterious  effects  upon  the  body  are  the 
result  of  a  lack  of  faith,  justifiable  or  unjustifiable,  on  the 
part  of  the  individual  in  his  own  ability  to  protect  himself 
against  real  or  fancied  hostile  environmental  elements,  so 
we  see  that  any  agency  which  can  dispel  worry  or  can  over- 
come fear  will  at  once  stop  these  body- wide  stimulations  and 
inhibitions  which  cause  lesions  that  are  as  truly  physical 
lesions  as  are  fractures.  The  striking  benefits  of  good  luck, 
success  and  happiness;  of  changes  of  scene;  of  hunting  or 
fishing;   of  optimistic  and  helpful  friends,  are  at  once  ex- 


THE    CLINICAL    PATHOLOGY   OF   SHOCK 


97 


plained  on  this  hypothesis.  One  can  also  understand  the 
sudden  change  from  the  broken  body  and  cowed  spirits  of 
an  animal  in  captivity  to  a  buoyant  normal  condition  when 
freed. 

These  facts,  proyed  by  common  daily  experience  in  the 
clinic  and  in  the  laboratory,  show  how  disastrous  may  be  the 
effect  of  the  terror  and  anxiety  natural  to  the  patient  who 
contemplates  a  surgical  operation  upon  himself,  even  if  all 
effects  of  the  actual  trauma  are  obviated  (Fig.  23). 


tso 

3 

/to 

■S30 

/to 

//a 

/OP 

fa 

ys 

9^ 

Fig.  23.  Effect  of  Strong  Emotion  Fbab  upon  thi  Pui 
The  patient,  a  foreigner,  was  brought  to  the  operating-room  from  the  acci- 
dent ward,  Pulse  ana  temperature  normal.  When  be  found  bimself  in  the 
operating-room  be  was  greatly  disturbed.  It  was  impossible  ti>  make  him 
understand  thai  hi-  leg  mu  not  i<i  \»-  amputated,  bul  only  :i  plaster  cast 
applied.  Under  this  physical  stimulus  In-  pulse  rose  to  150,  and  soon  be 
dr\ eloped  a  temperature  "t  mi  .2    F. 

7 


98  ANOCI-ASSOCIATION 

Every  surgeon  knows  how  much  better  are  his  results  in 
the  case  of  the  phlegmatic  patient,  who  views  with  uncon- 
cern the  preparations  for  the  approaching  ordeal,  than  in 
that  of  the  high-strung,  nervous  patient,  whose  terror  may 
reach  such  a  degree  that  the  fear  phenomena  are  evident 
throughout  the  operation  in  the  increased  circulation,  the 
irregular  heartbeat,  the  rapid  and  shallow  respiration, 
sweating,  tremors,  etc. 

In  addition  the  patient  who,  prior  to  his  operation,  is 
convinced  that  he  will  die,  usually  does  die.  The  quiet 
settled  conviction  is  as  potent  in  its  effect  as  is  the  terror 
which  holds  the  bird  motionless  as  he  watches  the  approach- 
ing serpent.  The  operation  may  be  an  exploration  for  a 
suspected  cancer,  of  the  existence  of  which  the  patient  feels 
absolutely  certain.  If,  after  the  operation,  he  is  told  that 
no  cancer  was  found,  he  is  sure  that  the  surgeon  has  in- 
vented a  fiction  for  his  encouragement  and  that  an  inoper- 
able cancer  actually  exists.  The  patient  has  heard  often 
of  such  means  being  taken  to  bolster  up  the  courage  of  the 
hopeless.  If  he  be  a  physician,  he  may  himself  have  been 
a  party  to  such  a  deception.  The  force  of  this  conviction 
will  probably  overbalance  all  the  efforts  of  his  surgeon. 
The  overwhelming  stimulus  in  such  a  case  is  the  same  as 
that  which  depresses  the  animal  in  captivity,  or  that  which 
in  our  laboratory  injured  the  brains  of  our  frightened  rab- 
bits, and  threw  excessive  amounts  of  glycogen  and  adrenalin 
into  the  blood  of  our  frightened  cats;  the  same  as  that  which 
is  evident  in  the  strain  and  stress  of  life  everywhere. 

In  these  hopeless  patients  one  sees  a  drawn  face;  the 
expression  is  despairing;  digestion  and  metabolic  changes 
are  arrested;    and  insomnia  is  almost  if  not  quite  uncon- 


THE    CLINICAL    PATHOLOGY    OF    SHO<  K  99 

querable.  These  clinical  observations  are  at  variance  with 
the  pulse  and  temperature,  but  the  hopeful  chart  ultimately 
becomes  as  grave  as  the  facies  and  to  the  astonishment  of 
all  but  the  experienced,  death  follows. 

Internet-  as  well  as  surgeons  recognize  that  recovery  is 
impossible  or  is  at  least  prolonged  in  the  patient  who  does 
not  try  to  get  well;  and  even-  epidemic  attests  the  fact  that 
many  of  the  victims  are  half-killed  by  fear  before  the  disease 
begins  its  easy  task. 

In  the  hospital,  then,  as  in  sports,  in  competition  of  every 
kind,  in  war,  in  every  phase  of  life,  faith  in  the  outcome 
makes  a  good  fighter  and  is  half  the  battle.  The  surgeon 
who  confine-  his  curative  measures  to  the  operating  room 
has  fought  but  half  his  battle,  for  a  favorable  outcome  will 
depend  not  only  upon  Ins  operative  skill  but  upon  the  success 
with  which  he  can  dispel  doubts  of  the  outcome  and  bolster 
up  the  confidence  of  his  patients  in  their  own  inherent 
ability  to  meet  the  stress  of  the  ordeal. 


CHAPTER  IV 

THE  KINETIC  THEORY  OF  SHOCK— SUMMARY 

There  is  a  group  of  organs  whose  function  is  the  conver- 
sion of  potential  into  kinetic  energy.  These  organs  form 
what  may  therefore  be  designated  a  Kinetic  System.  Among 
the  organs  forming  this  system  are  the  brain,  the  thyroid, 
the  suprarenals,  the  muscles  and  the  liver.  The  Kinetic 
System  converts  latent  energy  into  motion  or  heat  in  re- 
sponse to  adequate  stimuli.  If  the  stimuli  are  overwhelm- 
ingly intense,  then  the  Kinetic  System — especially  the  brain 
— is  exhausted,  even  permanently  injured.  This  condition 
is  acute  shock.  If  the  stimuli  extend  over  a  period  of  time 
and  are  not  so  intense  as  to  cause  an  immediate  breakdown 
or  acute  shock,  their  repetition  may  cause  the  gradual  ex- 
haustion of  the  Kinetic  System — a  condition  which  may  be 
called  chronic  shock.  Either  acute  or  chronic  shock  may 
be  measurably  controlled  by  weakening  or  breaking  the 
kinetic  chain  at  any  point. 

In  other  words,  shock  is  the  result  of  an  intense  stimula- 
tion of  the  Kinetic  System, — by  physical  exertion,  emotion, 
trauma,  toxins,  anaphylaxis,  strychnin,  etc. — which  leads  to 
physical  changes  in  the  Kinetic  Syste?n  and  which  if  carried 
far  enough  exhausts  that  system.  The  Kinetic  System  is 
constantly  activated  as  long  as  there  is  life,  but  normal 
activation  does  not  produce  exhaustion.  If  normal  activity 
of  the  Kinetic  System  be  exemplified  by  walking,  shock  might 
be  exemplified  by  the  exhaustion  caused  by  a  Marathon  race. 

100 


THE   KINETIC   THEORY   OF   SHOCK— SUMMARY  101 

The  difference  between  normal  processes  and  shock  is  that  of 
intensity,  not  of  kind.  From  these  premises  it  becomes  ob- 
vious that  the  exclusion  of  both  traumatic  and  emotional 
stimuli  will  wholly  prevent  the  shock  of  surgical  operations. 


PART  II 

THE  TREATMENT  OF  SHOCK  AND  ITS 

PREVENTION  THROUGH  ANOCI- 

ASSOCIATION 

I'.Y  GEORGE  W.  CRELE,  M.  I>..  AM)  WILLIAM   E.  LOWER,  M.  I). 
"There  are  Burgeons  who  operate  upon  the  'canine1  principle  of  Bavage 
attack,  and  the  biting  and  tearing  of  tissues  arc  terrible  to  witness.    These 
are  they  who  operate  with  one  eve  upon  the  clock,  and  who  judge  the  beauty 

of  any  procedure  by  the  fewness  of  the  minutes  which  it  ha-  taken  to  complete. 

There  are  other  surgeons  who  believe  in  the  'light  hand,' who  use  the  utmost 
gentleness,  and  who  deal  lovingly  with  every  tissue  that  they  touch. 
*************** 

"The  scalpel  is,  indeed,  an  instrument  of  most  precious  use    in  some  hands 

a   royal   BCeptrej     in   others   bul    a    rude   mattock.      The   perfect    BUTgeOD   inu-t 
have  the  'heart  Of  a  lion  and  the  hand  Of  a  lady';    never   the  claws  of  a  lion 

ami  the  heart  of  a  sheep."    Sib  Berkeley  Moynihan,  I'.  I!  C.  8. 


CHAPTER  V 

THE  TREATMENT  OF  SHOCK 

Since  shock  is  the  result  of  over-activation  and  consequent 
exhaustion  of  the  kinetic  system,  however  that  condition  has 
been  induced,  then  the  two  important  points  to  be  borne  in 
mind  in  its  treatment  are  (1)  the  prevention  of  further  shock 
by  the  amelioration  or  elimination  of  the  conditions  which 
produced  it ;  and  (2)  the  support  of  the  circulation:  in  other 
words,  (1)  the  energy  still  remaining  in  the  kinetic  system 
must  be  conserved;  and  (2)  the  destructive  effects  of  anemia 
must  be  overcome. 

(1)  To  accomplish  the  first  end  the  surgeon  "must  check 
hemorrhage;  he  must  relieve  pain;  he  must  remove  anxiety 
and  distress.  Even  in  those  cases  of  shock  which  have 
Buffered  their  misfortune  before  the  surgeon  sees  them  he 
can  assisl  greatly  by  helping  to  blunt  the  sensibilities  and  to 
quiel  apprehension.  For  this  purpose  morphin  is  the  sur- 
geon's sheet-anchor"    Mumford  i. 

In  our  histologic  studies  of  shock,  we  have  proved  thai 
stimulating  drugs  cause  brain-cell  exhaustion.  Their  use 
in  the  treatment  of  shock,  therefore,  is  as  illogical  as  would 
be  .-in  attempl  to  ward  off  bankruptcy  by  spending  more 
money.  In  facl  we  have  found  thai  the  administration  of 
large  doses  of  strychnin  is  cue  of  the  mosl  efficienl  means 
of  producing  shock.  ( >n  the  other  hand,  morphin  and  seda- 
tives generally  do  not  cause  the  expenditure  of  energy  but 
aid  in  its  conservation;    such  drugs,  therefore,  are  of  the 

105 


106  ANOCI-ASSOCIATION 

greatest  value  directly  by  preventing  the  further  exhaustion 
of  the  kinetic  system  and  indirectly  by  inducing  a  quiet 
state  of  mind  and  body  which  further  serves  the  same 
purpose. 

(2)  Our  extensive  researches  to  discover  whether  brain 
anemia  might  be  safely  overcome  by  saline  infusions  showed 
conclusively  that  the  blood  can  only  temporarily  be  safely 
diluted  with  saline  solution,  and  that  the  only  medium  that 
will  remain  in  the  circulation,  that  will  do  the  work  of  blood, 
and  that  when  introduced  in  large  enough  quantities  will 
develop  a  peripheral  resistance  by  distending  the  elastic 
blood-vessels,  is  human  blood. 

This  point  having  been  determined,  it  became  necessary 
to  work  out  the  problem  of  the  transfusion  of  blood,  first  by 
experiment  in  the  laboratory,  later  by  practical  application  in 
the  clinic.  This  has  proved  to  be  the  ideal  treatment  for  grave 
cases  of  shock.  Indeed,  almost  no  case  of  shock  will  die  from 
the  shock  alone  if  given  an  adequate  and  timely  transfusion 
of  human  blood.  The  transformation  of  the  patient  is  dra- 
matic, especially  in  those  cases  of  shock  in  which  hemorrhage 
is  an  important  factor.  It  should  be  noted  also  that  since 
low  blood-pressure  deteriorates  the  brain-cells,  the  collapse 
itself  may  be  obviated  by  timely  infusion.  Several  years 
ago,  we  found  in  our  investigation  that  beheaded  dogs  could 
be  kept  "alive"  a  half  day  or  longer  either  by  slow  adrenalin 
infusion  or  by  overtransfusion  of  blood,  by  which  means  a 
normal  blood-pressure  was  maintained  without  assistance 
from  the  brain.  The  transfusion  of  blood  is  a  specialized 
technique,  the  details  of  which  should  be  mastered  in 
advance  of  the  emergency. 

Prophylaxis  is  of  more  value  than  treatment,  however, 


THE    TREATMENT    OF    SHOCK  107 

and  to  the  efficient  prevention  of  shock,  the  Kinetic  Theory 
has  found  the  way.  If  shock  be  the  result  of  exhaustion  of 
the  organs  of  the  kinetic  system,  especially  of  the  brain, 
this  exhaustion  being  caused  by  traumatic  stimuli,  then  if  all 
noti-stimuli,  traumatic  and  psychic,  can  be  removed,  the 
patient  will  be  in  a  state  of  complete  anoci-association.  In 
as  far  as  this  ideal  state  can  be  approached,  in  so  far  will 
surgical  operations  become  shockless. 


CHAPTER  VI 
ANOCI-ASSOCIATION 

Principle.  General  Technique;  Morphin  and  Scopolamin;  Nitrous-Oxid- 
Oxygen;  Novocain;  Quinin  and  Urea  Hydrochlorid ;  Gentle  Manipulations; 
Sharp  Dissection. 

PRINCIPLE 

On  the  Kinetic  Theory  already  enunciated  in  the  fore- 
going chapters  of  this  book  a  new  principle  of  operative  sur- 
gery has  been  founded,  the  " paramount  object  of  this  new 
technique  (being)  to  reduce  the  toxic  action  of  the  general 
anesthetic  and  the  traumatic  factor  of  the  operative  manip- 
ulations to  a  minimum"  (Bloodgood). 

As  already  stated,  every  adequate  stimulus  with  or  with- 
out inhalation  anesthesia,  whether  from  trauma  or  emotion, 
activates  the  kinetic  system,  causing  the  brain-cells  to  dis- 
charge some  of  their  stored  energy — that  is  to  say,  the  sight 
of  the  operating  room,  the  spoken  word  implying  danger, 
the  taking  of  the  anesthetic,  the  instrumental  injury  of 
tissues  in  the  course  of  the  operation,  and  the  traction  of  the 
stitches  after  the  operation,  all  are  adequate  stimuli.  Ob- 
viously the  only  practical  method  of  preventing  the  con- 
sumption of  the  energy  stored  in  the  brain-cells  is  the  de- 
velopment of  an  operative  technique  which  will  exclude  from 
the  brain  the  stimuli  of  the  special  senses  and  the  stimuli 
of  common  sensation. 

The  principle  of  anoci-association  may  be  illustrated  by 
the  wrecked  Titanic.  The  story  of  the  stress  and  the  psychic 
strain  of  the  survivors  is  known,  that  of  the  lost  may  be 

108 


ANOCI-ASSOCIATION  109 

easily  imagined;  the  future  haunting  memory  of  this  ex- 
perience in  the  minds  of  the  survivors  may  be  safely  pre- 
dicted. Now,  if  a  survivor  of  this  ship  had  been  so  skil- 
fully anesthetized  in  his  bed  just  before  the  accident  that  he 
knew  nothing  of  the  impending  disaster,  and  if  he  then  had 
been  gently  carried  up  on  deck,  lowered  into  a  lifeboat,  and 
taken  aboard  the  rescue  ship  without  being  allowed  to 
awaken  from  his  anesthesia  until  he  was  safely  in  bed  again 
in  a  comfortable  state-room, — if  then  he  had  been  told  thai 
he  had  been  transferred  from  the  sinking  ship,  but  that  now 
he  was  safe  and  would  soon  see  his  home,  he  would  have 
passed  through  the  accident  in  a  state  of  anoci-CLSSOciation. 

Is  there  a  single  anesthetic  that  will  exclude  all  nocuous 
or  harmful  physical  and  psychic  stimuli  from  the  brain? 
By  blocking  nerve  conduction  local  anesthetics  protecl  the 
brain  from  the  effects  of  local  operative  injury,  but  they  do 
not  protect  the  brain  against  destructive  psychic  strain;  in- 
halation anesthetics  exclude  the  psychic  stimulation  of  the 
brain-cells,  but  do  not  exclude  the  operative  stimulation;  and 
genera]  anesthetics  introduced  hypodermically,  being  un- 
controllable, are  excluded  on  principle.  Bach  anesthetic 
covers  a  pari  of  the  field,  bul  there  is  qo  single  agenl  thai 
aloru  can  produce  anocirossociation,  which  i-  the  goal  of 
operative  surgery.  We,  therefore,  do  nol  advocate  ether 
alone,  nor  chloroform  alone,  nor  nitrous-oxid-oxygen  alone; 
we  do  noi  advocate  local  anesthesia  alone,  nor  morphin  and 
scopolamin  alone,  aor  spinal  anesthesia  alone,  bul  through 
selection  and  combination  of  anesthetics  we  aim  to  attain  the 
anesthesia  thai  in  the  case  in  hand  will  exclude  all  stimuli 
from  the  brain,  and  thereby  attain  anocirossociation. 

We  propose  to  discuss  the  technique  by  which  a  state  of 


110  ANOCI-ASSOCIATION 

anoci-association  has  been  attained  in  certain  major  opera- 
tions; to  show  that  not  only  the  immediate  operative  re- 
sults but  the  postoperative  morbidity  and  mortality  as  well 
are  lessened  or  eliminated.  It  may  be  well  first,  however, 
to  say  a  few  words  regarding  the  anoci-association  environ- 
ment which  should  be  sought  and  which  has  a  scarcely  less 
important  bearing  upon  the  outcome  of  the  operation  than 
has  the  operative  technique  itself. 

The  surgeon's  best  assurance  for  the  successful  outcome 
of  a  serious  operation  would  be  to  have  the  patient  come 
under  his  care  long  before  the  development  of  the  trouble 
from  which  relief  is  desired.  Unfortunately — or  fortunately, 
according  to  one's  point  of  view — this  possible  factor  of 
success  is  not  within  the  reach  of  any  individual  or  surgeon. 
The  surgeon,  however,  who  too  often  must  deal  with  pa- 
tients heavily  handicapped  by  factors  which,  if  known  in 
time,  might  have  been  controlled,  is  finding  that  by  a  care- 
ful, unhastened  preparation  of  his  patient  he  may  do  much 
to  counteract  the  adverse  conditions. 

In  other  words,  the  work  of  the  surgeon  does  not  begin 
in  the  operating  room,  nor  with  the  immediate  mechanical 
preparation  of  the  patient  for  operation,  nor  does  it  end  with 
the  healing  of  the  physical  wound.  In  the  operating  room 
and  during  the  process  of  healing  also  the  patient  must  be 
considered  as  a  whole.  That  is,  the  surgeon,  and  the  mem- 
bers of  his  office  staff,  the  hospital  superintendent,  the 
intern,  the  nurse,  the  orderly — every  one  who  comes  into 
relation  with  the  patient — must  bear  in  mind  that  even 
apparently  slight  factors  may  contribute — mightily  even- 
to  his  ultimate  welfare.  Already  we  have  come  to  realize 
to  some  extent  that  human  beings  are  integral  organisms 


ANOCI-ASSOCIATION  111 

and  that  one  part  cannot  suffer  without  the  coincident  suffer- 
ing of  all  the  rest.  Yet  we  are  prone  to  forget  that  the 
reverse  of  this  proposition  must  be  true  also, — that  any 
factor  which  contributes  to  the  welfare  or  improvement  of 
the  condition  of  one  part  will  contribute  also  to  the  welfare 
of  all  the  rest . 

We  have  stated  the  importance  of  the  emotional  factor  in 
producing  shock.  If  the  natural  fear  of  the  approaching 
ordeal,  which  is  felt  by  every  normal  individual,  be  aug- 
mented by  tactless  words  in  a  surgeon's  consulting  room;  by 
an  ungracious  reception  at  the  hospital;  by  inconsiderate 
treatment  by  a  nurse  or  orderly;  by  the  sound  of  clanking 
instruments;  by  the  rough  or  forced  administration  of  an 
anesthetic;  then  the  resistance  of  the  patient,  which  is 
already  depleted  by  his  diseased  condition,  will  be  lowered 
still  further.  No  matter  how  perfeel  and  non-shocking 
in  itself  may  be  the  technique  of  the  operation,  the  results 

are  -till  prejudiced  by  these  other  adverse  factors. 

By  an  assuring  preoperative  environment ;  by  the  definite 
dulling  of  the  nerves  through  the  administration  of  a  nar- 
cot  ic;  by  a  non-suffoc.-it  ing  odorless  inhalation  anesthel  ic;  by 
:i  local  anesthetic  to  cut  off  all  afferenl  impulses  during  the 
fourse  of  t  he  operation ;  by  a  second  Local  anesthetic  of  lasting 
effect  to  protect  the  patient  during  the  painful  postoperative 
hours;  by  gentle  manipulation  and  sharp  dissection,  by 
the  combination  of  .-ill  these  methods,  the  patient  is  pro- 
tected from  damage  from  every  factor  excepting  those  which 
exist  in  the  diseased  condition  from  which  relief  is  Bought 
Fig.  -i  . 

The  anoci-association,  however,  due-  not  end  in  the  oper- 
ating room,  nor  with  the  return  of  the  patient  to  his  bed. 


112 


n 


ANOCI-ASSOCIATION 

n  hi 


^ 


Fig.  24. — Schematic  Drawing  Illustrating  Protective  Effect  of  Anoci- 

Association. 

I.  Conscious  patient  in  whom  auditory,  visual,  olfactory  and  traumatic 
noci-impulses  reach  the  brain. 

II.  Patient  under  inhalation  anesthesia  in  whom  traumatic  noci-impulses 
only  reach  the  brain. 

III.  Patient  under  complete  anoci-association;  auditory,  visual,  and  ol- 
factory impulses  are  excluded  from  the  brain  by  the  inhalation  anesthesia; 
traumatic  impulses  from  the  seat  of  injury  are  blocked  by  novocain. 

Postoperative  environmental  conditions  are  no  less  essential 
than  preoperative.  To  perform  a  shockless  operation  on  a 
bad  risk  and  then  have  the  patient  distressed  and  nagged  by 
poor  after-care  is  like  putting  tacks  on  the  smooth  pavement 
in  the  path  of  an  automobile  after  driving  it  safely  over 
rough  roads.  To  achieve  the  shockless  operation  the  pa- 
tient must  be  received  and  carried  through  a  complete  anoci- 
association;    not  only  the  surgeon  himself,  but  assistants, 


AXOCI- ASSOCIATION  113 

interns,  anesthetists,  hospital  officials  and  nurses  must  be 
intelligently  and  specially  trained — but  above  all,  it  must 
be  borne  in  mind  that  no  detail  is  too  petty  for  the  careful 
attention  of  the  surgeon  himself. 

GENERAL  TECHNIQUE 
MORPHIN  AND  SCOPOLAMIN 

To  mitigate  the  preoperative  dread  and  to  facilitate  the 
induction  of  anesthesia,  a  solacing  dose  of  morphin  and 
Bcopolamin  (usually  morphin,  ',  gr.,  scopolamin,  ,l„  gr.iis 
given  an  hour  before  the  operation  to  all  patients  excepting 
fche  aged,  the  very  young,  and  those  whose  feeble  condition 
contraindicates  the  use  of  these  narcotics.  The  use  of 
morphin  serves  the  double  purpose  of  diminishing  the  pre- 
operative psychic  strain  and  of  actually  preventing,  to  some 
extent,  fche  damage  to  fche  organs  of  fche  kinetic  system  by 
the  trauma  of  fche  operation.  Laboratory  experiments  have 
shown  that  in  morphinized  animals  subjected  to  trauma,  the 
changes  in  the  cells  of  the  brain,  fche  suprarenals,  and  fche 
liver  arc  less  than  in  traumatized  animals  without  this 
protection. 

That  deep  morphinization  will  almost  completely  pre- 
vent shock  has  been  abundantly  proved  in  both  the  labora- 
tory and  fche  clinic  A  striking  confirmation  of  this  fact  is 
found  in  the  following  case: 

The  patient  was  a  woman  46  years  of  age  with  ob- 
struction of  the  bowels  from  a  large  Bolid  tumor  which  oc- 
cupied the  entire  abdomen  and  caused  distention  greater 
even  than  pregnancy  at  term.  This  tumor  had  been  ex- 
plored six  nths  previously  by  a  skilful  colleague  who  had 

wisely  judged  fche  case  to  be  Inoperable,  the  urgent  condition 


114  ANOCI-ASSOCIATION 

of  obstruction  not  being  present  at  that  time.  When  the 
patient  came  to  us  she  was  weak,  emaciated  and  was  run- 
ning a  slight  daily  fever.  Under  anoci-association  the  ab- 
domen was  opened  and  a  careful  search  was  made  for  the 
obstruction. 

The  widespread  adhesions  and  the  actual  inclusions  of 
the  viscera  in  the  growth  soon  showed  us  that  we  could  not 
relieve  the  obstruction  without  attempting  the  apparently 
impossible  removal  of  the  tumor.  When  this  decision  was 
reached,  the  pulse  had  mounted  to  142  and  the  respiration 
to  38. 

The  completion  of  the  operation  would  mean  resection 
of  the  bladder  and  of  part  of  the  small  intestine.  Nerve 
blocking  in  these  deep  fused  structures  was  impossible. 
Transfusion  would  be  insufficient  to  relieve  the  situation. 
Death  was  certain  if  we  retreated  and  apparently  equally 
certain  if  we  proceeded.  In  no  case  could  a  new  resource 
be  more  urgently  needed. 

It  was  at  once  decided  to  apply  our  laboratory  findings 
regarding  the  protective  effects  of  morphin.  The  operation 
was  interrupted — the  patient  being  kept  under  the  light- 
est possible  nitrous-oxid-oxygen  anesthesia — while  morphin 
was  given  in  quarter-grain  doses  at  ten-minute  intervals 
until  the  respiration  had  fallen  from  32  to  12  per  minute. 
We  then  resumed  the  tedious  and  difficult  task  of  separating 
the  huge,  solid,  adherent,  semi-malignant  tumor  by  means 
of  sharp  dissection.  To  accomplish  this  separation,  it  was 
necessary  to  resect  a  portion  of  the  small  intestine,  the  entire 
fundus  of  the  bladder  and  several  inches  of  the  right  ureter, 
the  proximal  end  of  which  was  implanted  into  the  back  by 
Bottomley's  method.     The  tumor  had  been  unable  to  gain 


A.NOCI-ASSOCIATION  115 

a  sufficient  blood  supply  through  its  original  pedicle  and  had, 
therefore,  made  many  vascular  connections  with  the  neigh- 
boring organs  and  consequently  much  blood  was  unavoid- 
ably lost  during  the  operation.  To  counteract  the  resultant 
anemia  a  transfusion  of  blood  from  the  patient's  sister  was 
given. 

At  the  close  of  the  operation  and  the  transfusion,  the  res- 
piration ranged  from  (5  to  10  per  minute  and  the  pulse  rate 
was  134. 

The  patient  was  placed  in  bed  in  a  modified  fowler  posi- 
tion and  sodium  bicarbonate  and  glucose  were  given  im- 
mediately by  the  drop  method  per  rectum,  while  sufficient 
morphin  was  given  in  repeated  doses  during  the  first  24  hours 
t.»  hold  the  respiration  to  12  per  minute.  The  patient  made 
a  splendid  recovery  from  the  operation. 

The  protective  effect  of  morphin  is  remarkably  exhibited 
also  in  those  cases  of  exophthalmic  goiter  in  which  some  ex- 
ceptional local  condition  causes  a  break  in  the  complete 
anoci-association  of  the  patient,  as  a  consequence  of  which 
the  pulse  and  respiration  increase  markedly  during  or  niter 
the  operation.  In  these  cases,  if  morphin  be  given  in  re- 
peated doses  until  the  respiration  and  pulse  are  held  sta- 
tionary or  fall,  the  dangerous  exhaustion  of  the  patient  will 
be  avoided.  The  morphin  may  be  given  at  any  time  during 
or  after  the  operation  when  it  is  seen  that  the  patient's  en- 
ergy is  being  expended  at  ton  rapid  a  rate. 

Morphin  is  especially  useful  also  in  those  cases  of  acute 
infection  in  which  emergency  operations  must  be  performed. 
In  Buch  cases  morphin  affords  a  double  protection  it  pro- 
tects the  brain  against  both  the  infection  and  the  operative 
trauma,  the  effects  of  which  are  increased,  because  during 


116  ANOCI-ASSOCIATION 

the  activations  of  a  toxin,  the  brain  thresholds  are  greatly 
lowered.  Here  also  morphin  should  not  be  given  in  one 
dose,  but  in  repeated  doses  until  the  physiological  effect  is 
produced.  This  point  will  be  indicated  by  the  reduction 
of  the  respiration  to  the  normal  rate  or  less. 

In  brief,  by  proper  use,  morphin  to  a  large  extent  controls 
the  metabolic  processes.  It  should  be  added  that  it  is  not 
our  intention  to  suggest  an  increase  in  the  use  of  morphin 
in  average  cases,  but  to  emphasize  its  usefulness  when  em- 
ployed in  physiologic  dosage  in  certain  exceptional  cases. 

NITROUS-OXID-OXYGEN 

A  full  description  of  the  technique  in  use  in  the  authors' 
clinic  for  the  administration  of  nitrous-oxid-oxygen  will  be 
given  in  a  later  chapter  by  Miss  Hodgins.  Here  it  is  in 
place  to  repeat  that  nitrous-oxid-oxygen  is  the  anesthetic  of 
choice,  as  it  is  odorless;  a  few  inhalations  are  sufficient  to 
induce  unconsciousness;  it  is  less  apt  to  cause  nausea  than 
is  ether;  and,  in  a  great  measure,  it  protects  the  brain-cells 
from  exhaustion. 

In  the  choice  of  the  anesthetic,  however,  it  should  be 
emphasized  that  the  patient  is  the  first  consideration  and  not 
the  prejudice  of  the  surgeon  for  a  certain  method.  If  ni- 
trous-oxid-oxygen does  not  fully  anesthetize  the  patient,  as 
may  happen  in  some  cases  and  frequently  does  with  ine- 
briates, then  in  addition  sufficient  ether  should  be  given  to 
attain  the  desired  end. 

It  should  also  be  borne  in  mind  always,  that  while  nitrous- 
oxid-oxygen  is  the  safest  of  all  anesthetics  in  the  hands  of  an 
expert  in  the  technique  of  its  administration,  it  is  perhaps 
the  most  unsafe  in   the  hands  of  the  inexperienced  and, 


AXOCI-ASSOCIATIOX  117 

therefore,  it  should  never  be  administered  except  by  an 
anesthetist  specially  trained  in  its  use. 

In  training  our  first  nitrous-oxid-oxygen  anesthetist,  we 
experiment ed  on  dogs  not  patients.  Only  after  the  dangers 
and  pitfalls  had  been  discovered  and  mastered  in  the  labor- 
atory did  we  cautiously  introduce  this  anesthetic  into  our 
clinic.  The  training  of  the  second  anesthet  isl  was  more  easily 
accomplished,  as  the  first  was  ready  to  supervise  every  ad- 
ministration of  the  anesthetic.  Lakeside  Hospital  now  has 
three  trained  nitrous-oxid-oxygen  anesthetists. 

In  the  days  when  nitrous-oxid-oxygen  was  first  used,  in- 
juriously impure  gas  was  sometimes  sold,  the  short  anes- 
thesia for  dental  purposes  scarcely  disclosing  the  defects. 
With  the  new  demand,  the  methods  of  manufacture  have  im- 
proved. The  best  assurance  of  pure  gas  supplied  at  an 
even  flow  is  secured  when  oitrous-oxid-oxygen  is  manufac- 
tured at  the  hospital  and  supplied  from  large  gasometers 
to  the  operating  room.    The  nitrous-oxid-owgcn  used  at 

Lakeside  Hospital   is  supplied  from  a   plant   which  has  been 

perfected  by  Dr.  A.  \l.  Warner  and  is  described  by  him  in 

a  later  chapter. 

The  anesthetists  at  Lakeside  Hospital  and  Dr.  Teter  have 
administered    oitrous-Oxid-OXygen    Is. 250   times   for   general 

surgical  operations,  and    16,714   times  for  oral   operations 
makings  total  of  34,964  general  anesthetizations  without 
.1  fatality. 

NOVOCAIN 

Every  division  of  a  sensitive  tissue  thai  is,  of  a  tissue 
supplied  with  nociceptor-  is  preceded  by  the  injection  of 
aovocain  in  I :  LOO  solution.  This  is  used  routinely  in  all  parts 
of  the  body,  in  all  ages,  m  the  debilitated  and  in  the  strong, 


IIS  ANOCI-ASSOCIATION 

in  small  and  in  extensive  operations  under  all  sorts  of  con- 
ditions. There  are  certain  salient  points  to  be  observed  in 
its  use: — the  tissue  to  be  divided  should  be  completely  infil- 
trated— no  nerve  filament  should  be  omitted.  One  might 
think  of  the  novocain  as  a  stain  and  consider  that  only  the 
stained  parts  are  ready  for  the  knife.  The  infiltrated  parts 
should  be  subjected  immediately  to  pressure,  as  firm  pres- 
sure with  the  hand  greatly  increases  the  efficiency  of  the 
anesthetic  and  the  extent  of  the  anesthetized  area. 

It  is  well  to  make  the  first  infiltration  between  the  super- 
ficial and  deep  layers  of  the  skin  in  such  a  manner  as  to 
cause  a  pig  skin  appearance.  This  is  facilitated  by  putting 
the  skin  on  tension  and  then  while  making  the  injection, 
pushing  the  needle  along  in  the  skin  parallel  to  the  surface. 

Experience  in  operating  under  local  anesthesia  alone  is 
almost  essential  for  learning  how  to  use  novocain  infiltra- 
tion effectively,  for  the  conscious  patient  promptly  protests 
if  the  infiltration  is  incomplete.  As  a  result  of  an  abundant 
experience  with  conscious  patients,  the  surgeon,  even  when 
operating  on  anesthetized  patients,  will  automatically  plan  the 
infiltration  and  handling  of  the  viscera  in  the  manner  which 
would  cause  the  least  response  were  his  patient  conscious. 

It  is  obvious  that  the  anesthetic  solution  should  be  most 
carefully  prepared  and  sterilized.  In  our  clinic  this  is  done 
as  follows:  Normal  saline  solution  is  prepared  with  distilled 
water  and  boiled  for  twenty  minutes.  A  sufficient  number  of 
novocain  crystals  are  added  to  make  a  1 :  400  solution  which  is 
then  boiled  for  ten  minutes  on  two  successive  days. 

Novocain  when  properly  injected  anesthetizes  the  part 
immediately;  the  anesthesia  lasts  for  approximately  an  hour; 
and  it  presents  no  interference  to  the  healing  of  the  wound. 


ANOCI-ASSOCIATION 


119 


QUININ  AND  UREA  HYDROCHLORID* 

To  minimize  postoperative  discomfort,  especially  in  ab- 
dominal operations,  quinin  and  urea  hydrochloric!  in  a   £ 


- 

z 
- 
- 
- 
o 
- 
a 

- 


-  a 
z 


- 

: 


•The  anesthetic  propertiea  of  tlii-  drug  were  discovered  by  Thibault,  of 
Bcott,   Irkai 


120  ANOCI-ASSOCIATION 

to  Yi  per  cent,  solution  is  injected  at  a  distance  from  the 
wound.  The  effects  of  this  local  anesthetic  last  for  several 
days,  so  that  by  its  use  the  patient  is  protected  from  noci- 
impulses  from  the  operative  field  until  the  healing  process 
has  well  begun.  This  local  anesthetic  can  be  safely  used  in 
all  cases  in  which  no  infection  is  present,  but  is  unsafe  in  the 
presence  of  infection  because  it  to  some  extent  diminishes 
the  resistance  of  the  tissues.  Quinin  and  urea  hydrochlorid 
usually  causes  some  edema  of  the  infiltrated  part  which  may 
last  for  weeks,  but  which  ultimately  disappears.  The  solution 
used  at  Lakeside  Hospital  is  prepared  by  boiling  distilled 
water  for  twenty  minutes;  adding  a  sufficient  number  of 
sterile  quinin  and  urea  tablets  to  make  a  solution  of  the  re- 
quired strength  and  boiling  again  for  ten  minutes. 

Moynihan  has  devised  an  excellent  syringe  having  an 
obtuse-angled  needle  by  means  of  which  the  quinin  and 
urea  hydrochlorid  may  be  injected  at  a  distance  from  the 
incision  so  that  the  entire  operative  field  will  be  anesthetized 
for  two  days  or  more  after  the  operation,  while  the  wound 
itself  is  not  exposed  to  the  irritation  of  the  quinin  and  urea 
(Fig.  25). 

GENTLE  MANIPULATIONS:  SHARP  DISSECTION 
The  phylogenetic  facts  upon  which  the  kinetic  theory 
of  shock  is  founded  indicate  the  necessity  for  the  use  of  the 
gentlest  manipulations  throughout  the  operation.  In  this 
respect  the  surgeon  should  at  all  times  govern  his  move- 
ments as  he  would  if  the  patient  were  to  be  conscious  of 
each  step  in  the  operation.  Pulling,  tearing,  and  crushing 
manipulations  awaken  phylogenetic  noci-associations  with 
consequent  activation  for  defense,  and  exhaust  the  organs 


ANOCI-ASSOCIATION  1-1 

composing  the  kinetic  system,  especially  the  brain.  In  ad- 
dition actual  coincident  trauma  is  produced  by  traction  in 
the  tissues  beyond  the  zone  which  is  protected  by  the  in- 
filtration of  the  local  anesthetic.  On  the  other  hand  the 
division  of  the  tissues  with  a  sharp  scalpel  is  a  form  of  injury 
which  awakens  less  phylogenetic  association  and,  in  addi- 
tion, produces  the  least  amount  of  damage  to  the  tissues. 
Gentle  manipulation  and  sharp  dissection  by  producing 
the  least  amount  of  tissue  injury  in  turn  necessitate  the 
minimum  amount  of  healing.  Clean-cut  wounds  aire  the 
least  postoperative  discomfort.  It  should  be  borne  in  mind 
also  that  trauma,  by  diminishing  their  vitality,  predisposes 
the  tissues  to  infection.  For  every  reason,  therefore,  the 
tissue  trauma  should  be  as  slight  as  possible. 


CHAPTER  VII 

ANOCI-ASSOCIATION  IN  ABDOMINAL  OPERATIONS 
Biologic  Considerations.     General  Technique 

BIOLOGIC  CONSIDERATIONS 

Adequate  stimulation  of  the  nociceptors  implanted  in 
the  abdominal  wall,  like  adequate  stimulation  of  the  noci- 
ceptors elsewhere,  causes  muscular  response.  In  the  con- 
tractile response  of  the  abdominal  muscles,  however,  an  in- 
creased intra-abdominal  pressure  is  produced,  as  a  result  of 
which,  when  the  abdomen  is  opened,  the  smooth,  lubricated 
intestinal  coils  slip  with  wonderful  facility  out  of  the  wound. 
Not  only  does  this  expulsion  of  the  intestines  greatly  hinder 
the  operator  in  his  work,  but  it  is  an  additional  source  of 
injury  to  the  patient,  for  the  added  manipulation  of  the  in- 
testines required  to  replace  them  adds  greatly  to  the  pro- 
duction of  shock. 

Muscular  contractions  of  the  abdominal  wall  may  be  pre- 
vented by  the  administration  of  an  anesthetic  which  will 
produce  in  the  brain  such  a  deep  state  of  anesthetic  paralysis 
that  no  adaptive  muscular  response  will  be  made  to  the  op- 
erative stimuli  which  are  received  by  the  brain-cells.  Less 
muscular  relaxation  is  produced  by  nitrous-oxid-oxygen 
anesthesia  than  by  either  of  the  lipoid-solvent  anesthetics 
— chloroform  and  ether.  For  this  reason  nitrous-oxid- 
oxygen — a  less  paralyzing  anesthetic — does  not  prevent 
the  adaptive  contractile  response  of  the  strong  abdominal 
muscles  during  injury  to  the  abdominal  wall  as  completely 
as  either  chloroform  or  ether. 

122 


ANOCI-ASSOCIATION   IN    ABDOMINAL    OPKHATIONS 


123 


, 


I  i<.   26      Abdominal  Operations:  [nfii/tration  01  Skin  ind  Subcutanb- 

01  -  " I " i  —  i  I  -   wiiii    \>  p\  oi   \i  \. 


A\OCI-ASSO<  IATIOX    IX    ABDOMINAL    OPERATIONS         125 

To  prevent  expulsion  of  the  intestines,  therefore,  one 
must  either  employ  the  lipoid-solvent  ether  in  rather  large 
dosage,  or  one  must  prevent  the  impulses  of  the  operative 
trauma  from  reaching  the  brain.  This  latter  resull  may  he 
accomplished  by  the  use  of  either  spinal  anesthesia  or  local 
anesthesia. 

(a)  Spinal  anesthesia  would  be  the  method  of  choice  had 
it  not  three  disadvantages:  first,  spinal  anesthesia  causes 
a  considerable  fall  in  the  blood-pressure  because  it  cuts  off 
nerve  communication  with  the  vasomotor  center  in  the 
brain  from  a  large  vascular  field — the  splanchnic  territory 
and  the  lower  extremities;  second,  thus  far  the  mortality 
rate  with  spinal  anesthesia  is  higher  than  with  ether  or  ni- 
trous-oxid-oxygen;  and  third,  since  the  patient  is  conscious 
he  undergoes  a  heavy  psychic  strain.  Minor  disadvantages 
arc  postoperative  headache  and  the  fact  that  analgesia  is 
occasionally  incomplete. 

b)  Local  Anesthesia.  There  is  ample  evidence  thai  many 
abdominal  operations  may  be  painlessly  performed  under 
local  anesthesia  alone:  bul  as  with  spinal  anesthesia,  in  the 
average  patient  thai  stringent  and  most  exhausting  emo- 
tion     tear      is  excited  by  the  knowledge  lint    I  he  abdomen 

IB  open,  thai  serious  conditions  may  arise,  and  thai  grave 
consequences  may  ensue.  Such  a  psychic  ordeal  may 
break  down  the  bravesl  patient  and  cause  not  only  mental 
distress,  but,  as  we  have  shown  elsewhere,  actual  physical 
injury  a>  well.  The  flushed  or  pallid  and  sweat-covered 
face  of  the  conscious  patient  portrays  all  too  well  his  deep 
apprehension  and  distress  far  beyond  the  possibility  of 
assuagement  by  any  effort  on  the  part  of  the  operator.  In 
routine  operation-,  therefore,  On  laparotomized  patient 
should  /"  asU  (  p. 


12G 


ANOCI-ASSOCIATION 


GENERAL  TECHNIQUE 
Excepting  to  the  very  young,  the  aged  and  patients  with 
depressed  vitality,  ,r  gr.  morphin  and  Ti7  gr.  scopolamin 
are  administered  one  hour  before  the  operation.  The  young, 
the  old,  and  certain  handicapped  patients  are  not  given  this 
preoperative  sedative  dose. 


Fig.  27. — Abdominal   Operations:     Infiltration  of  Fascia  and  Muscle 

with  Novocain. 

The  skin  is  infiltrated  with  novocain  in  1 :  400  solution  in 
such  a  manner  as  to  produce  a  broad,  white  elevated  strip 
of.  skin  within  which — strictly  within  which — the  incision  is 
made  (Fig.  26).  The  razor-edged  knife,  at  a  low  speed  so 
controlled  that  the  line  of  incision  may  not  pass  the  anes- 
thetized zone,  divides  the  skin  and  the  underlying  fat.     As 


ANOCI-ASSOCIATION    IN    ABDOMINAL   OPERATIONS        127 

iat   is  but  sparsely  supplied   with   nociceptors,  this  tissue 

may  be  divided  down  to  the  external  fascia  without  novo- 
cain infiltration. 

The  external  fascia  is  next  infiltrated  carefully  and  is  di- 
vided  by   the   controlled   passage — not  sweep — of  a  sharp 


in.    28      Abdominal  Operations:    Infiltration   01    Posterior  Sheath 
wii  Perj  roNEi  m  wn  a  Novo*  mn. 

Bcalpel,  and  then  in  succession  the  muscles,  the  posterior 
Bheath  and  the  peritoneum  arc  anesthetized  and  divided 
Figs.  27  and  28  . 

\  soon  as  the  abdomen  is  opened  quinin  and  urea  hydro- 
chlorid  in  a  ,'  to  '.  per  cent,  solution  is  used  in  a  massive 
infiltration  of  the  abdominal  wall,     at  a  distana    from  llic 


128 


ANOCI-ASSOCIATION 


incision, — the  infiltration  being  so  complete  that  the  entire 
operative  field  is  physiologically  severed  from  the  brain 
(Fig.  29) .     The  effect  of  quinin  and  urea  hydrochlorid  lasts 


PERITONEUM 
MUSCLE 

FASCIA 


Fig.  29.— Abdominal  Operations:    Infiltration  with  Quinin  and  Urea 
Hydrochlorid  at  a  Distance  from  the  Incision. 

for  two  days  or  more  and  minimizes  postoperative  shock 
and  gas  pain. 

If  the  principle  of  anoci-association  be  carried  out  in  every 
detail,  then,  no  matter  what  may  be  the  location  or  the 
length  of  the  abdominal  incision,  the  intestines  will  be  within 
the  abdominal  cavity  and  the  abdominal  muscles  will  be 
completely  relaxed  (Fig.  30).  Under  these  conditions 
the  entire  abdomen  may  be  explored  without  awakening 
the  nociceptor  sentinels.     If   the  incision  be  long,  the  en- 


ANOCI-ASSOCIATION    IX    ABDOMINAL    OPERATIONS        129 


I  i...  30     Completely    Relaxed  Abdominal  Wall  ind  [nte8tine8, 
i  mi    Result  oi     I  nod-  1  aociation. 


ANOCI-ASSOCIATION    IN    ABDOMINAL   OPERATIONS        131 

tire  wall  may  be  elevated  with  the  warm,  moistened,  gloved 
hand  and  mosl  of  the  viscera  inspected  literally.  The  hand 
may  then  go  gently  bul  completely  over  every  viscus  and 
explore  every  nook  and  corner  of  the  abdomen  without  dis- 
turbing the  original  complete  muscular  relaxation. 

It  may  happen,  however,  in  spite  of  biologic  strategy, 
that  the  existing  conditions  may  make  it  impossible  to 
avoid  the  stimulation  of  nociceptors,  so  that  muscular 
contractions  are  present.  In  such  a  case  the  oitrous-oxid- 
oxygen  should  not  be  pushed  an  atom  beyond  the  pink  stage, 
but  ether  should  be  added  until  the  needed  relaxation  is 
reached — a  few  minutes  and  but  little  ether  are  usually  suffi- 
cient to  attain  this  end.  In  rare  instance-  ether  may  he 
administered  on  ;i  cone  during  the  delivery  of  an  adherent 
tumor. 

Owing  to  the  entire  relaxation  of  complete  anoci- 
O88ociation  l>nt  tew  if  any  intra-abdominal  pads  are  required. 
Nowhere  is  the  law  of  consequences  more  truly  exemplified 
than  in  abdominal  operations.  In  no  instance  does  the 
punishment  more  truly  lit  the  crime.  Sow  roughness  and 
reap  .-i  harvest  of  postoperative  distress. 


CHAPTER  VIII 

ANOCI-ASSOCIATION    IN    ABDOMINAL    OPERATIONS- 
CONTINUED 

Operations  on  the  Gail-Bladder.  Common  Duct  Operations.  Operations  on 
the  Stomach.  Resection  of  the  Intestines.  Herniotomy.  Perineal  Opera- 
tions. 

OPERATIONS  ON  THE  GALL-BLADDER 

If  the  mucous  membrane  of  the  gall-bladder  be  gan- 
grenous; if  there  be  a  stone  embedded  by  ulceration  in  the 
cystic  duct;  if  the  wall  of  the  gall-bladder  be  thickened  by 
scar  tissue  as  a  reaction  to  infection ;  and  if  there  be  no  bile 
in  the  gall-bladder, — these  conditions  usually  are  followed 
by  recurrent  obstruction  and  infection.  On  the  other  hand, 
if  the  gall-bladder  have  approximately  normal  walls,  and  if 
the  cystic  duct  be  approximately  normal,  then  no  matter 
what  the  size  or  the  number  of  stones,  if  the  operation  be 
performed  with  gentle  manipulation  so  as  to  avoid  any  un- 
necessary trauma,  there  will  be  no  postoperative  patho- 
logic cycle.  Too  much  stress  cannot  be  laid  upon  the  neces- 
sity for  gentle  manipulation  in  the  performance  of  the  oper- 
ation. What  would  happen  to  the  urethra  if  a  clumsy 
hand  attempted  to  guide  into  the  bladder  a  metal  catheter 
or  sound  which  had  become  corrugated  by  age  and  neglect? 
Or  what  would  be  the  result  of  so  forcibly  stuffing  rough 
gauze  into  the  urethra  as  to  cause  copious  bleeding?  The 
urethra  would  swell,  become  infected,  obstructed,  and  later, 
perhaps,  strictured.  The  base  of  the  gall-bladder  and  the 
cystic  duct  resent  no  less  the  bruising  and  wounding  of 

132 


ANOCI-ASSOCIATION    IX    ABDOMINAL   OPERATIONS        133 

their  mucous  membranes  by  gauze  or  by  instruments. 
Following  such  needless  injury  there  may  be  occlusion  by 
strictures,  for  the  normal  cystic  duct  is  very  small  and  is 
easily  closed  by  stricture.  Finesse  can  accomplish  a  more 
certain  exploration  and  a  more  difficult  extraction  than  can 
rough  manipulation. 

In  the  cases  in  which  cholecystectomy  is  indicated,  the 
pathologic  condition  of  the  gall-bladder  would  make  cho- 
lecystectomy safer  than  cholecystostomy,  as  the  former 
obviates  the  necessity  for  prolonged  drainage  and  limits  the 
extent  of  infection,  especially  of  infection  of  the  incised  wall. 
The  mortality  of  cholecystectomy  depends  also  on  the  tech- 
nique. The  gall-bladder  should  be  exposed  by  an  ample 
wound  so  that  there  is  free  access  to  its  base;  the  freeing 
and  separation  of  tissue  should  be  made  b}r  sharp  dissection, 
care  being  taken  not  to  cut  into  the  liver,  thai  bleeding  and 
infection  in  thai  organ  may  be  avoided.  The  entire  gall- 
bladder should  be  freed  from  its  attachment  so  that  ample 
opportunity  may  be  given  for  determining  the  exact  place 

Where    the   gall-bladder    ends    and    the    cystic    duct    begins. 

This  technique  causes  bu1  little  reaction. 

An  ample  field,  anociated  by  novocain  and  by  a  massive 
inject  ion  of  quinin  and  urea  hydrochlorid  in  1 :600  solution 
into  the  abdominal  wall  at  a  distana  from  tin  lim  of  incision, 
gives  the  operator  his  maximum  opportunity  for  carrying 
out  the  intra-abdominal  pari  of  the  operation  without  drag- 
ging or  pulling,  but  with  sharp  dissection  and  the  mini- 
mum amount  of  bleeding.  Thus  the  operation  becomes 
shockless  while  the  postoperative  morbidity  is  minimized 
by  the  lasting  effect-  of  the  quinin  and  urea  hydrochlorid 
inject  ion. 


134 


ANOCI-ASSOCIATION 


In  cases  showing  chronic  infection  without  febrile  reaction 
the  risk  of  cholecystectomy  is  less  than  that  of  cholecystos- 
tomy.  But  in  cases  of  acute  cholecystitis  with  protective 
adhesions  in  which  the  cystic  duct  is  obstructed,  cholecys- 
tectomy will  give  a  higher  mortality  than  will  mere  drain- 
age of  the  gall-bladder,  for  the  reason  that  during  the  ex- 
cision of  the  viscus,  even  with  the  most  careful  technique, 
it  is  necessary  to  traumatize  the  surrounding  tissues  to  such 
an  extent  that  the  local  immunity  of  the  tissues  is  impaired. 
In  such  cases  it  is  probably  wiser  merely  to  drain  the  gall- 
bladder, interfering  with  the  local  tissues  as  little  as  possible. 
Later,  if  necessary,  the  gall-bladder  may  be  excised. 


Beit$. 

70 

80 

90 

100 

110 

120 

Ether 

NiO. 

Anoc'i. 

The    Pulse. 
Each  heavy  line  represents  the  average  5  p.  m.  pulse-rate  of  ten  patients  during  the  first  four 

days  after  operation. 

Fig.  31. — Comparative  Clinical  Results  of  Consecutive  Cholecystos- 
tomies  Performed  under  Ether  Anesthesia,  under  Nitrous-Oxid- 
Oxygen  Alone,  and  under  Complete  Anoci-association. 

COMMON  DUCT  OPERATIONS 

Operations  for  stone  in  the  common  duct,  even  in  the 
hands  of  the  most  experienced  and  expert  operators,  yield 
a  high  mortality  rate  as  compared  with  operations  on  the 
gall-bladder,  or  with  operations  on  the  pelvic  organs,  or 
with  operations  for  exophthalmic  goiter,  for  suppurative  ap- 
pendicitis, etc. 

In  the  common  duct  operation  no  vital  organ  is  involved 
—but  merely  a  duct.     Death  cannot  usually  be  attributed 


A\Ori-ASS(><  IATIOX    IN    ABDOMINAL    OPERATIONS         135 

to  the  loss  of  bile  or  to  infection  of  the  peritoneum  from 
bile,  but  is  due  to  the  gradual  development  of  an  asthenic 
state  characterized  by  dullness  of  the  mental  and  motor 
reactions,  a  dry  tongue,  partial  suppression  of  bile,  ano- 
rexia, scanty  urine, — together  with  the  impairment  of  the 
entire  digestive  system  a  progressive  adynamic  state 
which  is  extremely  resistant  to  any  known  treatment.  All 
common  duct  cases  by  no  means  follow  this  course,  but  the 
severity  of  the  postoperative  symptoms  is  in  proportion  to 
the  difficulty  of  the  technique,  which  in  turn  depends  upon 
the  number  of  the  stones  and  their  impactions.  One  most 
impressive  example  of  this  morbid  development  was  in  the 
case  of  a  fairly  good  risk  patient  whose  entire  common  duct 
and  a  large  part  of  the  hepatic  duct  were  impacted  solidly 
with  sixty-five  -tones.  The  task  of  extracting  these  was 
most  difficult  and  though  the  patient  went  through  the  op- 
eration splendidly,  he  died  on  the  fifth  day  with  the  symp- 
toms above  mentioned.  Neither  infection,  nor  hemorrhage, 
nor  -lock,  nor  ileus,  nor  pneumonia,  nor  urinary  suppression 

were  accountable      Wh;it  then  did  cause  death? 

A  clue  to  the  real  explanation  of  this  hitherto  baffling 
Sequence  of  common  duct  operations  was  found  jusl  at  this 
time  iii  the  following  facts  established  by  certain  experi- 
ments on  the  ductless  glands  which  were  being  made  at  the 
time  of  this  patient's  death.  The  liver  performs  its  func- 
tion in  pari  through  hormone  action  and  in  pari  through 
direct  innervation.  It  is  curious  thai  for  the  performance 
of  :it  least  a  part  of  it-  function  the  liver  requires  to  have  a 

simultaneous    hormone    and    nerve    stimulation.      Now     the 

nerve  Bupply  of  the  liver  is  derived  from  the  sympathetic 
By  stem,  the  nerve  liber-  passing  along  the  blood-vessels  Mini 


136  ANOCI-ASSOCIATION 

the  common  duct.  As  during  the  processes  of  evolution 
these  nerves  have  been  thus  abundantly  sheltered  against 
injury,  they  have  not  evolved  physical  qualities  for  their 
protection  as  have  the  peripheral  nerves.  It  would  appear 
that  in  the  course  of  common  duct  operations  for  stone,  per- 
formed by  an  operator  who  is  unaware  of  this  grave  danger, 
the  nerve  supply  to  the  liver  will  be  more  or  less  blocked 
traumatically.  If  the  block  be  light  and  the  patient  have 
sufficient  endurance,  the  temporary  loss  of  liver  function 
will  be  safely  bridged;  on  the  other  hand,  the  more  severe 
the  trauma  of  the  nerves,  the  more  completely  will  the 
nerves  be  blocked  and  the  longer  will  that  block  last.  This 
conclusion  corresponds  precisely  with  our  clinical  facts. 
It  gives  an  adequate  explanation  of  the  unexpected  death 
of  certain  patients,  and  makes  it  evident  that  surgery  has 
been  riding  rough-shod  over  a  serious  danger. 

To  obviate  this  danger  as  far  as  possible  the  following 
operation  was  planned :  Gentle  manipulations  and  sharp  dis- 
section are  employed  throughout,  the  whole  operation  being 
planned  so  as  to  subject  the  tissues  to  the  least  possible 
amount  of  trauma.  A  long,  vertical,  right  rectus  skin  in- 
cision is  made  with  a  transverse  incision  at  its  upper  end  ex- 
tending an  inch  or  more  across  the  upper  abdomen,  the  skin 
along  the  line  of  incision  having  first  been  infiltrated  thor- 
oughly with  novocain.  The  muscular  tissues  are  then 
thoroughly  infiltrated  with  novocain  and  the  incisions  car- 
ried down  to  the  peritoneum.  The  peritoneum  is  anes- 
thetized and  opened.  By  sharp  dissection  all  adhesions 
are  carefully  divided,  the  dissection  being  strictly  confined 
to  the  white,  bloodless  hair-line  between  the  peritoneum 
and  the  adhesion.     No  blood-vessel  crosses  this  dead-white 


AXOCI-ASSOCIATIOX    IX    ABDOMINAL    OPERATIONS        137 

line.  The  whole  line  of  dissection  being  bloodless, 
every  tissue  is  accurately  identified  and  no  sponging  is 
needed.  The  stones  are  laid  bare  by  an  ample  incision 
through  the  duct  wall,  and  are  picked  out  without  injuring 
the  duct  mucosa.     The  duct  is  then  closed  with  fine  chromic 


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Fig.  32.    Chart  Showing   phb  Uneventful  Clinical  Coursi    utter  ah 
ition  for  Common  I  >i  <  \  Stoni  I'i  rformed  i  ndeh  Anoci-association. 


nut  on  a  French  needle,  just  as  wounds  of  the  intestine  are 
closed,  provided,  of  course,  thai  bile  drainage  through  the 
ampulla  or  the  gall-bladder  is  assured.  It'  drainage  of  the 
duet  itself  l"'  n"i  required,  an  iodoform  drain  is  placed  near 
but   in>t   againsl   the  line  of  sutures.     The  pre-incision  in- 


138  ANOCI-ASSOCIATION 

filtrations  with  novocain  prevent  shock,  while  the  sharp 
dissection  and  gentle  manipulations  cause  the  least  pos- 
sible damage  to  the  important  portal  nerves  and  to  an  ex- 
ceedingly vulnerable  environment.  As  far  as  the  operation 
alone  is  concerned,  therefore,  convalescence  should  be  and  is 
quiet  and  uneventful.  Thus  in  gall-bladder  and  duct  surgery, 
anoci-association  plays  an  especially  beneficent  role.    (Fig.  32) . 

OPERATIONS  ON  THE  STOMACH 

Anoci-association  in  operations  on  the  stomach  requires 
that  the  abdominal  wall  be  blocked  by  novocain  infiltration 
and  that  sharp  knife  dissection  be  used  for  the  division  of 
adhesions  and  the  preparation  of  the  operative  field,  that  is, 
the  principle  of  anoci-association  contraindicates  absolutely 
the  tearing  division  of  adhesions  by  blunt  force,  the  forcible 
insertion  of  the  blade  of  the  forceps  under  the  stomach,  or 
the  forcible  traction  of  the  stomach  up  into  the  wound.  The 
reason  is  clear — while  the  stomach  and  intestines  have  no 
nociceptors  for  cutting,  burning,  or  even  for  crushing,  they 
do  make  vigorous  protests  against  distention,  traction,  and 
friction. 

By  biologic  strategy,  however,  shock  may  be  eliminated 
from  gastric  operations — gastric  resection  and  gastroenter- 
ostomy. 

A  preliminary  transfusion  of  blood  will  bring  back  the 
vitality  of  patients  exsanguinated  by  hemorrhage.  Trans- 
fusion is  useful  in  starvation  cases  also,  although  these  pa- 
tients cannot  be  as  successfully  reclaimed.  For  here  the 
risk  is  not  one  of  shock  and  depression,  but  of  a  broken 
metabolism  which  will  express  itself  in  acidosis.  Since  they 
have  employed  transfusion,   the   authors  have   seen  more 


ANTOCI-ASSOCIATTON    IN    ABDOMINAL    OPERATIONS         139 

clearly  the  danger  of  acidosis,  for  occasionally  cases  all  but 
moribund  which  have  passed  through  the  operation  with 
apparent  safety  have  died  later  from  acidosis.  A  large 
volume  of  blood  and  a  fair  blood-pressure  cannot  prevent 
the  fatal  issue  of  the  acidosis  which  results  from  the  too 
extreme  previous  starvation. 

In  cases  of  gastric  ulcer,  partial  gastrectomy  is  the  opera- 
tion of  choice,  partly  because  of  the  uncertain  cure  by  gas- 
troenterostomy; and  partly,  as  Mayo  has  convincingly 
shown,  because  of  the  probability  of  cancer  development. 
In  cases  of  duodenal  ulcer,  however,  there  is  but  slight 
probability  of  cancer  development  and  the  ulcer  is  curable 
by  gastroenterostomy.  The  cure  of  duodenal  ulcer  may  be 
hastened  by  the  temporary  closure  of  the  pylorus.  The 
physiologic  adjustment  of  the  stomach  and  the  intestines 
will  occur  more  promptly  when  the  principle  of  anoci- 
O880ciation  is  strictly  adhered  to. 

To  diminish  the  postoperative  discomfort-  of  stomach 
operations  the  entire  operative  field  is  Infiltrated  with 
quinin  and  urea  hydrochlorid  Injected  with  the  Moynihau 
syringe  at  a  distanct  from  the  incision.  This  distana  I >1< >«-k- 
i 1 1 Li  is  especially  necessary  in  these  cases,  since  in  both  gas- 
trectomy and  gastroenterostomy,  as  in  gall-bladder  and  duct 
operations,  the  wound  may  become  infected.  In  addition, 
tin  relatively  painless  stale  resulting  from  //"  quinin  <in<l  nr<<i 
infiltration  insures  freedom  of  expansion  in  the  hosts  of  ///< 
liimi.  mill,  therefore,  lessens  ///<■  possibility  of  postoperatm 
inn  umonia. 

An  ample  abdominal  incision,  such  a-  i-  -ecu  in  the  Mayo 
Clinic,  allow-  the  most  favorable  opportunity  for  light 
intra-abdominal  manipulations.    Surgeons  mould  be  keenly 


140  ANOCI-ASSOCIATION 

dissatisfied    with    the    high    mortality    which    still    follows 
gastrectomy  even  in  the  best  clinics. 

We  are  now  encouraged  to  believe  that  through  anoci- 
association  the  full  benefits  of  the  two-stage  gastrectomy  will 
be  realized.  This  vitally  important  matter  will  be  consid- 
ered in  the  chapter  on  the  Two-Stage  Operation. 

RESECTION  OF  THE  INTESTINES 

Gangrene  resulting  from  acute  intestinal  obstruction  and 
the  presence  of  cancer  are  the  two  conditions  for  the  relief 
of  which  a  resection  of  the  intestines  is  most  often  indicated. 
Whatever  the  condition  the  first  step  in  the  operation  is  an 
exploration  for  the  purpose  of  planning  the  operation  and 
developing  the  operative  field. 

The  first  important  step  is  to  make  an  ample  abdominal 
incision  under  complete  local  blocking  with  novocain,  for 
whatever  condition  may  be  found,  the  muscles  of  the 
abdominal  wall  will  then  be  relaxed;  the  exploration  will 
be  facilitated;  and  the  use  of  gauze  pads  will  be  reduced  to 
a  minimum. 

The  preliminary  exploration  may  unavoidably  cause  a 
certain  amount  of  trauma  in  the  unblocked  territory  es- 
pecially in  case  of  intestinal  obstruction.  In  such  a  case 
enough  ether  should  be  added  to  the  nitrous-oxid-oxygen  to 
ensure  complete  relaxation  until  the  completion  of  the  ex- 
ploration and  of  the  development  of  the  operative  field. 
The  ether  may  then  be  omitted  and  the  operation  carried 
on  under  nitrous-oxid-oxygen  alone. 

As  soon  as  the  abdominal  wall  is  opened  a  deep  infiltra- 
tion with  quinin  and  urea  hydrochlorid  is  made  at  a  dis- 
tance from  the  line  of  incision.     As  it  requires  from  fifteen 


AXOCI-ASSOCIATIOX    IX    ABDOMINAL    OPERATIONS         141 

to  twenty  minutes  for  the  quinin  and  urea  hydrochloric!  to 
become  effective,  novocain  is  depended  upon  to  produce 
immediate  anesthesia  in  the  local  field.  Before  the  effects 
of  the  novocain  have  disappeared,  the  quinin  and  urea 
hydrochlorid  will  have  become  effective  and  the  whole 
abdominal  field  will  then  remain  anesthetized  and  relaxed 
throughout  the  operation  and  indeed  for  several  days  there- 
after. 

In  a  resection  of  the  intestines  the  most  important  con- 
sideration is  the  proper  planning  of  the  scope  of  the  opera- 
tion. The  ample  incision  gives  the  optimum  opportunity 
for  exploration  and  obviates  the  necessity  for  dragging  the 
viscera  out  of  the  wound.  In  other  words,  it  makes  it 
possible  for  the  operation  to  be  taken  to  the  intestines.  The 
intestines  need  not  be  pulled  out  beyond  the  point  at  which 
definite  traction  on  the  mesentery  is  being  made. 

The  only  shock-producing  factors  in  operations  on  the 
intestines  are  traction  on  the  mesentery  and  traumatizatioD 
of  the  peritoneum.  Suturing,  cutting,  burning,  and  even 
crushing  the  intestines,  Independently  of  other  factors,  can- 
not produce  shock,  as  no  nociceptors  have  been  evolved 
against  these  types  of  I  rauma. 

.1  nod-a88odation  in  intestinal  operations  is  simple  enough. 
therefore,  as  it  mean-  merely  that  the  surgeon  musl  avoid 
dragging  manipulations,  packing  with  gauze,  and  heavy 
retraction  of  the  abdominal  wall,  and  that  he  must  minim- 
ize bleeding,  a  small  amount  of  which  is  inevitable. 

The  end  results  of  resection  of  the  intestines,  therefore, 
depend  very  largely  upon  the  precision  and  care  with  which 
the  operation  is  performed.  The  more  the  Bhock-producing 
factors  are  controlled,  the  better  will  be  I  he  condition  of  the 


142  ANOCI-ASSOCIATION 

patient  at  the  end  of  the  operation,  and  the  more  certainly 
will  he  overcome  infection,  if  any  be  present.  The  authors 
have  seen  a  great  improvement  in  both  the  immediate  and 
the  later  results  of  resections  of  the  intestines  since  they  have 
used  anoci-association. 

HERNIOTOMY 

After  a  herniotomy  performed  without  the  protection  of 
anoci-association  the  following  morbid  conditions  are  prom- 
inent:— gas  pain,  painful  swollen  testicle,  and  occasionally 
retention  of  urine.  The  testicular  and  the  gas  pain  may 
be  distressing  and  both  are  responses  to  needless  opera- 
tive trauma.  If,  in  the  course  of  a  herniotomy,  the  sac  and 
the  cord  be  grasped  and  torn  asunder  with  rough  gauze, 
the  assaulted  cord  and  the  testicle  will  later  bear  testimony 
to  their  injury  by  swelling  and  pain.  Such  harsh  treat- 
ment of  these  delicate  tissues  is  no  less  damaging  than 
would  be  the  procedure  of  removing  a  cinder  from  the  eye 
by  sand-papering  the  entire  cornea.  Here,  as  elsewhere, 
however,  the  untoward  results  may  be  obviated  by  strategy 
and  by  gentle  manipulations. 

As  in  all  operations  under  anoci-association,  every  division 
of  tissue  supplied  with  nociceptors  is  preceded  by  the  infil- 
tration of  the  part  with  novocain.  The  field  of  operation 
is  kept  free  from  blood  by  catching  the  few  blood-vessels  in 
the  skin  and  subcutaneous  tissues.  The  white  glistening 
fascia  has  no  blood-vessels  and  its  parallel  strands  may, 
therefore,  be  bloodlessly  divided  by  a  sharp  knife.  The 
under  surface  of  the  fascia  has  no  vessels  running  through 
it  at  right  angles  and  the  sharp-knife,  bloodless  dissection  is 
therefore  carried  down  to  the  glistening  border  of  Poupart's 
ligament.     In  like  manner  the  inner  fascia  is  bloodlessly 


ANO< '[-ASSOCIATION    IN"    ABDOMINAL    OPERATIONS         14o 

divided.  The  sac,  hernia,  and  cord  are  thus  exposed  and 
appear  bloodless  and  translucent,  but  the  bloodless  dis- 
section does  nol  stop  here  even  if  the  sac  be  old  and  have  for 
a  long  time  been  irritated  by  a  truss.  The  sac  is  picked  up 
with  forceps  and  is  freed  for  a  short  distance  with  a  sharp 
knife.  It  is  then  opened  between  two  small  Halstead  hemo- 
stats  and  the  forefinger  is  introduced,  the  sac  being  stretched 
over  it  like  the  finger  of  a  glove.  The  true  peritoneum  con- 
tains no  blood-vessels,  hence  there  is  a  white,  bloodless  line 
between  it  and  its  neighbors.  Therefore,  no  matter  how 
old,  how  large,  or  how  adherent  the  sac  may  be,  the  knife 
can  be  passed  all  the  way  around  it  along  this  bloodless  line. 
The  blood-vessels  are  the  key  to  this  bloodless  line  of  fusion 
between  the  sac  and  its  environment,  and  the  presence  of 
the  smallest  blood-vessel  will  mean  that  some  extra-peri- 
toneal tissue  is  still  on  the  sac.  After  the  dissection  is  well 
Started,  the  separation  of  the  sac  well  within  the  internal 
ring  will   be  easily  accomplished    if  the   assistant    keep    the 

tissue  t;mt  by  tension  with  small  forceps.  X<>t  a  single  ves- 
sel below  the  subcutaneous  veins  needs  to  be  tied;  and  the 
cord  is  not  handled  at  all,  the  sac  being  sharply  and  pre- 
cisely i'iit  live  from  it . 

By  this  technique,  the  sac  is  completely  excised;    the 

COrd    18  uninjured;  the   testicle  does  not   suffer  at  all  and  no 

suspensory  supporl  will  be  required.  A-  a  resull  of  the 
bloodless  dissection,  the  pillars  are  translucenl  and  their 
Btrength  and  value  can  be  more  accurately  estimated  so 
that  more  intelligent  use  may  be  made  of  them  in  the  repair. 
The  procedures  we  have  described  apply  particularly 
to  operations  for  the  radical  cure  of  inguinal  hernia,  but  in 
umbilical  and  postoperative  hernia,  the  need  for  sharp  blood- 
less dissecl ion  i-  equally  clear. 


144  ANOCI-ASSOCIATION 

Before  the  wound  is  closed  the  stump  of  the  sac  and  the 
tissue  at  a  distance  which  contains  the  nerve-supply  to  the 
field  of  operation  may  be  infiltrated  with  quinin  and  urea 
hydrochlorid,  in  1 :  600  solution,  though  even  without  this  pro- 
tection there  should  be  little  postoperative  discomfort  if  the 
anoci-association  technique  has  been  rigidly  observed.  In  an 
old  hernia,  however,  at  the  site  of  a  protracted  suppuration, 
quinin  and  urea  hydrochlorid  should  not  be  used.  The  spores 
of  the  colon  bacillus,  in  particular,  may  be  dormant  for  many 
years,  and  the  added  irritation  of  quinin  and  urea  hydro- 
chlorid may  facilitate — certainly  will  not  hinder — the  re- 
awakening of  the  infection. 

PERINEAL  OPERATIONS 

In  perineal  operations  the  field  to  be  dissected  is  blocked 
as  thoroughly  as  if  the  operations  were  to  be  performed 
under  local  anesthesia  alone.  Stitch  tension  is  made  as 
slight  as  possible,  as  tight  stitches  not  only  are  painful  but 
cause  tissue  damage  from  pressure.  After  the  operation  is 
completed  the  area  included  in  the  stitches  is  blocked  by 
quinin  and  urea  hydrochlorid  in  1 :  600  solution,  injected  at  a 
distance  from  the  mucous  membrane  and  the  line  of  incision. 

RECTAL  OPERATIONS 

In  rectal  operations  one  has  a  splendid  opportunity  to 
test  the  value  of  novocain  infiltration.  The  divulsion  of 
the  sphincter  ani  causes  strong  reflex  action  and  is  a  momen- 
tary strain  on  the  anesthesia.  In  collapse  from  any  cause 
it  is  a  classic  procedure  to  make  use  of  the  vitalizing  effect 
of  sphincter  dilatation.  If,  however,  novocain  be  infiltrated 
into  the  soft  tissues  around  the  anus,  and  the  parts  be  then 
subjected  to  momentary  pressure,  then,  even  under  nitrous- 


ANOCT-ASSOCIATION    IN    ABDOMINAL    OPERATIONS        145 

oxid-oxygen  alone,  the  sphincter  may  be  completely  di- 
vulsed  without  any  noticeable  reaction. 

Postoperative  discomfort  is  an  almost  invariable  sequel 
of  anal  and  rectal  operations  especially  when  an  anal  tube 
is  worn.  This  may  be  greatly  diminished  if  the  entire  anal 
zone  be  blocked  by  quinin  and  urea  hydrochlorid  in  1:600 
solution  injected  at  a  safe  distance.  Bloodgood  states  that 
the  results  of  quinin  and  urea  infiltration  "in  its  elimination 
of  postoperative  pain  are  seen  chiefly  in  rectal  work." 

The  amount  of  postoperative  lumbar  and  sacral  pain  and 
of  pain  radiating  down  the  thighs  is  in  direct  proportion  to 
the  precision  and  gentleness  with  which  the  operation  is 
performed  as  well  as  to  the  care  with  which  the  quinin  and 
urea  infiltration  is  made. 


in 


CHAPTER  IX 

ANOCI-ASSOCIATION  IN  ABDOMINAL  OPERATIONS- 
CONTINUED 

Acute  Abdominal  Infections.     Acute  Appendicitis.     Acute  Infections  of  the 
Upper  Abdomen.     Pelvic  Infections.     Summary. 

ACUTE  ABDOMINAL  INFECTIONS 
In  describing  the  histologic  pathology  of  shock,  we  showed 
that  deterioration  of  the  cells  of  the  brain,  the  suprarenals, 
and  the  liver  may  be  caused  by  infection  alone,  by  trauma 
alone,  by  fear  and  worry  alone.  It  is  of  the  utmost  importance, 
therefore,  that  the  patient  handicapped  by  the  presence  of 
infection  should  be  scrupulously  protected  against  any  further 
drain  upon  the  organs  which  have  already  been  to  some  degree 
depleted.  Fear  and  worry  must  be  mitigated;  ether  avoided; 
and  the  local  field  completely  blocked  as  far  as  the  zone 
of  the  actual  infection.  In  these  cases,  however,  not 
only  the  cells  of  the  brain,  the  suprarenals,  and  the  liver, 
but  certain  other  cells — the  phagocytes — must  be  pro- 
tected as  well,  for  in  the  pyogenic  infections,  the  safety  of 
the  individual  depends  almost  exclusively  upon  these  or- 
ganisms. One  of  the  constituents  of  the  phagocytes  is 
lecithin,  which  is  soluble  in  ether.  Ether,  therefore,  by 
anesthetizing  the  phagocyte  as  well  as  the  patient,  causes  a 
weakening  of  the  body's  defense  which  lasts  for  from  twelve 
to  twenty-four  hours — a  break  in  the  defense  which  has  un- 
doubtedly cost  the  life  of  many  a  patient. 

To  anesthetize  the  phagocytes  in  the  presence  of  infection 

146 


ANOCI-ASSOCIATION    IX    ABDOMINAL    OPERATIONS         147 

is  as  serious  a  tactical  error  as  would  be  that  committed  by 
the  commander  of  a  fori  were  he  to  anesthetize  his  soldiers 
in  the  midsl  of  an  attack.  Ethei  and  chloroform  should  never 
be  employed  in  the  acute  infections.  Nitrous-oxid-oxygen 
does  not  in  any  way  affect  the  phagocytes  and  it  therefore 
causes  do  appreciable  alteration  in  the  mechanism  of  the 
body  designed  for  its  defense  against  infection.  In  addition. 
nitrous-oxid-oxygen,  unlike  ether,  causes  no  waste  of  energy 
as  a  result  of  the  intense  feeling  of  suffocation  which  so  fre- 
quently is  incident  to  the  inhalation  of  ether,  hence  to  that 
extent  nitrous-oxid-oxygen  conserves  the  body-  energies, 
and.  as  already  explained,  nitrous-oxid-oxygen  in  some  man- 
ner also  protects  the  brain-cells  from  the  damage  caused  by 
the  t  rauma  of  the  operation.  It  is.  therefore,  par  <  xc<  //<  na  . 
the  anesthetic  of  choice  in  infections.  The  evil  effect-  of 
trauma  and  of  ether  in  the  presence  of  acute  infection  have 
long  been  known  and  have  been  strongly  emphasized  by 
Murphy  and  by  Deaver,  the  former  calling  special  at  tent  ion 
to  the  necessity  of  Limiting  the  trauma;  the  latter  urging 
that  ilie  operation  be  performed  as  quickly  as  possible  to 
shorten  the  damaging  effect-  of  the  ether. 

To  demonstrate  the  protective  action  of  anocv-association 
in  the  acute  infections,  we  shall  discuss  it-  application  in 

acute  appendicitis;  in  infection-  of  the  Upper  abdomen; 
and  in  pelvic  infect  ions. 

ACUTE  APPENDICITIS 
It  the  infection   be  limited  in  the  appendix,  the  operation 

may  be  performed  under  anoci  protection  like  an  ordinary 
interval  appendectomy.  We  wish  here  to  discuss  the  pro- 
cedures in  appendicitis  with  spreading  peritonitis  or  abscess. 


148  ANOCI-ASSOCIATION 

The  patient  should  receive  hypodermic  injections  of  mor- 
phin  until  he  is  in  a  quiescent  state  and  should  then  be 
conveyed  in  the  Fowler  position  to  the  hospital  (Van  Buren 
Knott),  that  posture  being  maintained  throughout  his  journey 
to  the  operating-room,  the  operation,  the  return  to  his  room  and 
until  the  abdominal  infection  is  safely  overcome. 

The  operation  is  performed  under  nitrous-oxid-oxygen 
anesthesia.  The  line  of  incision  is  made  over  the  center  of 
inflammation,  the  division  of  the  abdominal  wall  being  pre- 
ceded by  novocain  infiltration.  The  incision  is  always  inter- 
muscular, never  transmuscular.  In  the  majority  of  cases 
the  incision  will  fall  upon  the  right  iliac  fossa.  If  a  localized 
abscess  be  present,  it  is  opened  gently  and  cautiously  ex- 
plored with  the  finger,  the  appendix  being  carefully  lifted  up, 
tied  off  and  excised  in  its  place,  if  it  be  found  at  once  and  be 
not  too  firmly  imbedded  in  the  wall  of  the  abscess.  If  the 
appendix  be  not  found  readily,  then  its  removal  should  be 
left  for  a  second  operation  after  the  abscess  has  completely 
healed.  In  other  words,  the  protective  wall  of  granulation 
must  not  be  broken  through,  for  a  breach  in  this  protective 
structure  may  mean  spreading  peritonitis,  new  abscesses, 
pylephlebitis,  and  subphrenic  abscess. 

The  next  step,  though  extremely  simple,  is  of  the  great- 
est importance  as  it  is  a  measure  by  which  the  formation 
of  multiple  abscesses  in  the  course  of  convalescence  may 
be  prevented.  Through  the  McBurney  incision  a  slender, 
straight,  flexible  retractor  is  slid  along  the  pelvic  wall  to 
the  very  bottom  of  the  pelvis.  A  second  straight,  flexible 
retractor  is  then  slipped  along  the  first  retractor  to  the  very 
bottom  of  the  pelvis.  The  pus  wells  up  freely  between  the 
two  retractors;    it  is  not  even  mopped  out  but  is  let  alone 


A.\()(  I-ASSOCI.VIIOX    IX    ABDOMINAL    OPERATIONS 


149 


while  a  long  cigarette  drain  or  rubber  tube,  held  by  long, 
slender,  dissecting  forceps,  is  passed  down  between  the  re- 
tractors through  the  pus  to  the  bottom  of  the  pelvis  and 
held  there  while  the  two  guarding  retractors  are  smoothly 
withdrawn.  The  blades  of  the  dissecting  forceps  are  then 
spread  apart  so  that  neither  blade  is  in  contact  with  the 
drain,  and  they  too  are  carefully  withdrawn  so  that  the 
drain  is  left  ;i-  a  line  of  communication  between  the  Mc- 
Burney  intermuscular  incision  and  the  bottom  of  the  pelvis, 
the  point  to  which  the  pus  from  all  parts  of  the  abdomen  will 


3  e  Jits 

70 

80 

90 

100 

110 

120 

Ether. 

NlO. 

Anoci. 

'riic  r 
Each  heavy  line  represents  the  average  5  p.  m.  pulse-rate  of  ten  patients  during  the  tir-i  four 

days  after  operation. 

I  p.  33.  Comparative  Clinical Resi  ursoi  Conse<  i  rrvE  Appendei  roMiES 
Performed  under  Etheh  Anesthesia,  under  Nitrous-Oxid-Oxyqeh 
Alone,   \\i>  i  nder  Complete  Anod-association. 


naturally  gravitate.  If  this  maneuver  be  employed,  a  second 
abscess,  pylephlebitis,  or  subdiaphragmatic  abscess  will 
rarely  occur    Fig.  33  , 

In  the  after-care,  two  distincl  object-  are  to  be  sought: 
1     the  encouragement  of  the  local  immunity  and    2    the 
protection  of  the  kinetic  system  againsl   injury  by  toxins. 

1  Encouragement  of  local  immunity.  The  entire  ab- 
domen from  the  costal  border  down  to  the  pubes  and  around 
to  the  lumbar  muscles  is  covered  with  massive  hoi  packs 
which  are  kepi   in  place  day  and  night.      \  broad  electric 


150  ANOCI-ASSOCIATION 

pad  is  a  great  help.  The  Murphy  rectal  drip  and  the 
Ochsner  dietary  are  employed,  and  stomach  lavage  is  rarely 
required;  no  cathartics  are  given,  the  bowels  being  moved 
by  enemata.  The  wound  is  never  irrigated,  but  the  deep 
pelvic  drain  is  left  undisturbed  until  the  acute  stage  is  past. 

(2)  Protection  of  the  kinetic  system:  The  free  installation  of 
water  attained  by  the  Murphy  method  apparently  pro- 
tects the  kinetic  system  to  some  extent,  but  in  extreme  cases 
their  protection  is  directly  accomplished  by  deep  narcoti- 
zation with  morphin  or  some  other  opium  product.  It  was 
well  known  to  the  older  clinicians,  especially  to  Alonzo 
Clark  and  to  Flint,  that  deep  opium  narcotization  was 
an  efficient  treatment  for  peritonitis.  These  wise  and 
resourceful  clinicians  gave  opium  until  the  respirations 
were  much  below  normal,  as  low  even  as  ten  or  twelve  per 
minute.  The  appearance  of  patients  so  treated  would 
seem  to  indicate  that  they  are  perilously  near  death,  but  the 
condition  continues  unchanged  until  the  local  immunizing 
forces  overcome  the  infection.  Not  until  that  is  accom- 
plished is  the  patient  allowed  to  come  out  from  his  pro- 
longed sleep. 

Striking  proof  of  the  protective  action  of  morphin  against 
the  toxins  of  infection  is  shown  in  our  laboratory  experi- 
ments. It  is  obvious  that  in  the  infections  the  kinetic  system 
is  being  driven  by  nocuous  influences.  Since  these  nocu- 
ous influences  cannot  be  blocked  at  their  sources,  then  the 
kinetic  system  itself  must  be  protected  with  opium.  Trauma, 
fear,  strychnin  and  toxins  all  cause  the  discharge  of  energy 
in  a  muscular  defense;  apparently  toxins  in  addition  drive 
the  kinetic  system  to  discharge  energy  in  producing 
a  metabolic  defense — as  a  result  of  which  fever  ensues. 


AXOCI-ASSiH  IATIOX    IX    ABDOMINAL    OPERATIONS         151 

Deep  morphinization  protects  both  the  muscular  and  the 
fever  defense  mechanisms  from  the  forced  activity  which 
otherwise  would  drive  the  kinetic  organs  to  exhaustion — 
perhaps  to  death. 

In  the  state  of  deep  morphinization  hut  little  nutrition 
is  required, — indeed  the  patient  is  in  a  condition  closely  re- 
sembling hibernation.  This  elimination  of  the  need  for 
food  solves  also  one  of  the  most  difficult  problems  in  the 
treatment  of  peritonitis. 

Under  this  technique  the  authors  have  performed  332 
operations  for  acute  appendicitis  with  but  two  deaths. 

ACUTE  INFECTIONS  OF  THE  UPPER  ABDOMEN 

Acute  infectious  of  the  upper  abdomen  are  governed  by 
the  same  principles  as  those  already  considered  in  the  dis- 
cussion of  spreading  peritonitis  arising  from  an  infected 
appendix.  Acute  cholecystitis;  perforation  of  the  gall- 
bladder;    perforation  of  the  stomach  or  duodenum;    and 

acute  pancreatitis  Jill  demand  the  most  complete  anoci- 
O88ociation. 

In  empyema  of  the  gall-bladder  the  new  adhesions  about 
the  gall-bladder  are  separated  with  the  greatest  care  just 
enough  to  permit  an  opening  in  the  gall-bladder  for  the 
establishment  of  drainage.  Aside  from  this  the  defenses  es- 
tablished by  nature  are  left  undisturbed.  In  severe  gangren- 
ous cases  no  exploration  of  the  gall-bladder  should  be  made. 
for,  as  in  the  case  of  acute  appendicitis,  the  first  issue  is  to  aid 
nature  in  establishing  local  immunity.  \-  a  rule,  the  acute 
infections  of  t  he  gall-bladder  run  a  safe  if  stormy  course  and 
the  opera t ion  may  be  deferred  until  the  quiescent  stage. 

\cute  pancreatitis  calls  for  prompt  drainage.  In  cases 
of  gastric  and  duodenal  ulcer-,  in  which  the  point  of  leakage 


152  ANOCI-ASSOCIATION 

is  closed,  sufficient  drainage  may  be  established  by  the 
Fowler  posture  and  a  local  drain;  if  this  proves  insufficient 
a  small  suprapubic  drain  may  be  added. 

PELVIC  INFECTIONS 

Most  of  the  infections  which  arise  from  child-birth  may 
be  guided  to  a  safe  termination  by  the  routine  treatment 
for  postoperative  peritonitis.  If  the  stage  of  pus  formation 
be  reached,  however,  vaginal  puncture  must  be  made.  Neg- 
lected cases  of  septic  abortion  frequently  require  both  the 
vaginal  puncture  and  the  routine  postoperative  treatment 
for  acute  appendicitis. 

By  vaccine,  rest,  hot  packs,  and  hot  douches  acute  gonor- 
rheal infection  in  women  may  be  guided  safely,  either  to 
resolution  or  to  the  more  chronic  pyosalpingitis. 

It  should  be  emphasized  again  that  in  the  treatment  of 
all  acute  abdominal  infections,  psychic,  traumatic  and  pain- 
ful stimuli  or  noci-associations  should  be  as  rigidly  excluded 
as  are  the  toxic  stimuli  so  that  the  patient  may  rest  within 
the  protection  of  complete  anoci-association. 

SUMMARY 

The  value  of  anoci-association  in  the  acute  abdominal 
infections  is  most  strikingly  illustrated  by  a  comparison  of 
the  pulse-rate  during  and  after  operations  in  cases  of  acute 
appendicitis. 

A  study  of  45  consecutive  ether  cases  showed  an  average 
increase  of  8.4  beats  in  the  pulse-rate  in  the  first  twenty- 
four  hours  after  operation,  and  an  average  increase  of  15.4 
beats  during  operation;  while  the  45  consecutive  anociated 
cases  studied  showed  a  fall  of  2.26  beats  in  the  first  twenty- 
four  hours  after  operation,  and  a  fall  of  1.22  beats  during 
operation. 


CHAPTER  X 

ANOCI-ASSOCIATION    IN    GYNECOLOGIC    OPERATIONS 

Beniiin  Tumor.-.     Suspension  of  the  I'terus.     Pus  Tubes. 
BENIGN  TUMORS 

The  removal  of  benign  tumors,  excepting  those  wedged 
in  the  pelvis,  may  be  accomplished  under  complete  anoci- 
O88ociation  as  follows:  The  tumor  is  fully  exposed  through 
an  ample  incision  in  the  novocainized  abdominal  wall.  As 
the  opening  has  been  made  under  anoci-association,  do  trau- 
matic Impulse  has  reached  the  brain,  and  the  muscles  arc. 
therefore,  completely  relaxed,  so  thai  almost  do  retraction 
will  be  required;  and  do  gauze  pads  will  l>c  required  to  pre- 
vent the  expulsion  of  the  intestines,  which  the  force  of 
gravity  will  cause  to  lie  within  the  abdomen. 

If  the  tumor  is  ovarian  and  is  Large  and  if  there  are  ad- 
hesions in  the  accessible  field,  these  are  divided  within  the 
Darrow,  white  bloodless  line  in  the  peritoneal  surface  of  the 
tumor  by  a  knife  with  the  keenest  possible  edge.  However 
old  or  firm  the  adhesion  may  be,  do  blood-vessel  will  cross 
this  dead  white  line.  This  line  of  division  may  be  kepi 
Btraighl  and  its  breadth  increased  if  an  assistant  make 
steady  ten-ion  with  a  Large  piece  nt  gauze.  This  ten-ion 
aeed  not  must  not  be  sufficient  to  excite  docuous  im- 
pulses, but  should  be  sufficient  to  facilitate  the  sharp  di- 
vision of  this  white  line  of  fusion  between  the  tumor  and 
the  parietal  or  intestinal  peritoneum.    This  feather-edge  di- 

153 


154  ANOCI-ASSOCIATION 

vision  can  be  made  in  a  much  shorter  time  than  can  a  carniv- 
orous bloody  separation,  especially  since  it  eliminates  the 
time  required  by  the  latter  method  for  hemostasis  and  for 
fighting  with  belligerent  coils  of  intestines.  It  is  surprising 
to  what  a  depth  the  sharp  dissection  may  be  carried  within 
the  pelvis.  Even  beyond  the  reach  of  the  knife,  however, 
the  advantage  of  this  technique  becomes  obvious,  for  the 
exact  cleavage  line  being  established,  as  a  rule  the  remainder 
of  the  tumor — bluntly  but  with  finesse — may  readily  be 
separated  with  the  wet  gloved  hand. 

The  anoci  principle  obviously  demands  that  the  body  of 
the  tumor  itself  shall  not  be  delivered  by  assault,  but  by 
strategy — by  coaxing  pressure  and  lifting.  An  ample  field 
for  these  maneuvers  is  secured  by  the  absence  of  gauze 
packing,  which  is  rendered  unnecessary  by  the  complete 
abdominal  relaxation.  Almost  any  tumor,  excepting  those 
molded  into  the  pelvis  in  the  course  of  their  growth,  can 
be  delivered  without  the  slightest  tightening  of  the  ab- 
dominal muscles,  without  disturbing  the  even  curve  of  a 
single  respiratory  excursion. 

As  soon  as  the  tumor  is  delivered,  the  line  of  division  of 
its  attachments  is  novocainized.  Then  and  only  then  are 
the  clamps  applied. 

Clamp  compression  alone,  even  without  novocainization, 
would  cause  relatively  slight  nocuous  response.  Under  the 
old  technique,  the  common  error  at  this  point,  in  the  lang- 
uage of  golf,  was  that  of  "pressing";  that  is,  the  operator 
became  so  anxious  to  get  the  tumor  out  that  he  handled 
it  needlessly  and  harmfully.  As  a  consequence,  the  patient 
awoke  locally  and  made  a  mute  but  serious  protest  against 
the  injury.     The  surgeon,  showing  no  more  control  over  his 


ANOCI-ASSOCIATION    IX    GYNECOLOGIC    OPERATIONS      155 

movements  than  did  the  anesthetized  patient,  redoubled 
his  effort-  to  pull  open  wide  the  rebellious,  protesting,  ab- 
dominal muscles  and  to  thrust  back  the  protruding  intestine 
with  rough  gauze,  and  then  ensued  a  strange  contest  be- 
tween the  nocuous  surgeon  and  the  unconscious  patient  un- 
til one  or  the  other  was  overcome.  The  surgeon  having  the 
advantage  usually  vanquished  the  patient,  who  could  make 
only  a  partial  fight  could  fight  only  with  his  injured  ab- 
dominal muscles.  //  this  muscular  response  of  the  patient 
had  been  utilized  in  voice  and  speech,  the  unequal  struggh 
would  han  ceased  promptly,  and  the  energies  of  both  patient 
and  surgeon  would  have  been  const  end. 

In  the  anoci  operation  the  surgeon  arrays  himself  on  the 
side  of  the  patient  and  by  blocking  the  QOCi-ceptors  of  the 
broad,  the  round,  the  utero-sacral  and  the  utero-lateral  liga- 
ments, he  keeps  the  nerve-muscular  mechanism  of  the 
pal  ient  in  ignorance  of  his  maneuvers. 

The  authors  have  never  seen  any  evidence  of  nociceptors 

for  -harp  knife  cutting  in  the  body  of  a  tumor  or  in  the  nor- 
mal uterus.  When  removing  a  tumor,  therefore,  it  is  neces- 
sary to  anesthetize  only  thai  part  which  is  to  be  grasped  \\  Lth 
the  forceps. 

The  stump  containing  the  divided  vessels  should  be 
blocked.  In  a  hysterectomy  one  is  apl  to  Buture  too  much 
tissue  and  to  tie  it   too  tightly.     Ochsner  Long  ago  called 

attention  to  this  point,  and  Bartlett  has  shown  that  pre- 
cision in  vascular  control  requires  that  accurate  attention 
be  given  i<>  the  main  vascular  trunks,  alter  which  the  re- 
mainder <>i  the  wound  may  be  closed  a-  one  closes  an  ex- 
ternal wound. 
John  G.  ('lark  ha-  demonstrated  how  practical  vascular 


156  ANOCI-ASSOCIATION 

control  without  excessive  suturing  may  be  secured  in  myo- 
mectomy. In  this  phase  of  the  operation,  the  golden  sur- 
gical rule  that  gentle  accuracy  should  be  employed  rather 
than  needless  force,  is  especially  applicable.  If  the  patient 
be  a  bad  risk,  then  the  strain  from  every  suture  or  ligature 
should  be  blocked  with  quinin  and  urea  hydrochlorid  in- 
jected at  a  distance  from  the  cut  surface. 

By  means  of  the  strategically  curved  needle  of  Kelly, 
Franklin  Martin's  long  dissecting  forceps,  the  Andrews 
needle  holder  and  long,  flexible  retractors,  any  part  of  the 
pelvis  may  be  sutured  with  accuracy  and  dispatch  in  the 
field  relaxed  under  anoci-association. 

PUS  TUBES 

In  cases  of  chronic  gonorrheal  salpingitis,  with  or  without 
tubal  abscess,  the  sharp  knife  dissection  gives  ready  access 
to  the  precise  cleavage  line.  Beginning  at  the  most  ac- 
cessible point,  the  adhesions  are  divided  by  sharp  dissection 
as  far  as  possible.  The  adhesions  may  be  so  thick  and  their 
fusion  with  the  intestinal  coils  so  firm  as  to  occasion  a  good 
deal  of  difficulty,  but  usually  at  some  point  the  tubo-in- 
testinal  cleavage  line  will  be  reached,  after  which  the  sepa- 
ration will  be  readily  made. 

By  anoci-association  one  may  deal  readily  even  with  those 
cases  in  which  the  uterine  fundus  is  well  up  in  the  pelvis, 
the  proximal  end  of  the  tube  being  thickened  but  not  ser- 
iously involved,  while  at  the  distal  end  the  fimbriated  ex- 
tremity has  grasped  the  ovary  and  is  pouring  into  it  a  bur- 
den of  infection,  causing  tubo-ovarian  abscess. 

With  a  sharp  knife  the  diseased  tube  is  freed  from  the 
uterus  by  means  of  a  V-shaped  cut;    the  bleeding  points 


ANOCI-ASSOCIATION    IX    GYNECOLOGIC    OPERATIONS      157 

being  caught  with  a  Kelly  needle  and  plain  catgut  in  an 
interlocking  suture  lightly  tied.  The  tubal  attachments 
are  divided  and  sutured.  The  tube  extends  down  into  the 
pelvis  like  an  inverted  pyramid;  its  attachments  may  be 
divided  with  ease,  and  finally  the  pus  tube  may  be  lifted  out. 

In  case  of  a  double  tubo-ovarian  abscess,  a  part  of  one 
or  of  both  ovaries  and  any  uninfected  portion  of  the  ovarian 
attachments  are  preserved.  Division  of  the  ovary  does 
not  cause  the  slightest  pain. 

If  the  uterus  be  down  in  the  pelvis,  with  the  tubes  and 
ovaries  above  it,  it  will  be  found  that  the  abscesses  extend 
well  downward  toward  the  fundus  uteri.  In  such  a  case 
the  ovaries  usually  fare  better  and  the  uterus  worse.  The 
latter  may  be  enlarged,  edematous,  heavy  and  infected.  In 
many  such  cases  it  is  necessary  to  remove  a  portion  of  the 
uterus  and  the  tubes  en  masse.  Here  anoci-association  is 
best  attained  by  taking  the  operation  to  the  field  rather  than 
by  dragging  the  organs  up  to  the  level  most  convenient  for 
the  surgeon.  In  an  adequate,  relaxed  field,  by  strategic 
maneuvers,  the  uterus  and  tubes  may  be  divided  by  a  sharp 
knife  the  sharp  knife  division  causing  not  :i  single  break  in 
the  respiratory  rhythm. 

SUSPENSION  OF  THE  UTERUS 
In    the   Coffey   operation,    which    we   usually  employ,  the 
broad  and  the  round  Ligaments  may  in  certain  cases  be 

blocked. 


CHAPTER  XI 
ANOCI-ASSOCIATION  IN  GENITO-URINARY  OPERATIONS 

Bladder.     Prostate.     Kidney. 
BLADDER 

In  preparation  for  any  operation  within  the  genito-urinary 
tract,  especially  for  operations  upon  the  bladder  and  pros- 
tate, the  bladder  is  filled  with  a  5  per  cent,  solution  of 
alypin  after  the  preliminary  dose  of  morphin  and  scopola- 
min  has  produced  its  effect.  By  this  means  the  mucosa  is 
sufficiently  anesthetized  to  prevent  nerve-muscular  responses 
to  the  operative  manipulations. 

The  skin,  subcutaneous  tissues  and  muscles  are  infiltrated 
with  novocain  (Fig.  34).  After  the  incision  has  been  made, 
the  bladder  is  brought  up  into  the  wound  by  gentle  traction 
with  a  pair  of  bladder  hooks,  and  the  line  of  incision  through 
the  bladder  wall  is  completely  blocked  (Fig.  35).  The  com- 
bination of  the  infiltration  of  the  bladder  wall,  with  the  pre- 
operative injection  of  alypin  will  so  completely  anesthetize 
all  areas  of  the  bladder  that  the  manipulations  of  operations 
for  stone,  for  tumor,  or  for  diverticula,  even,  may  be  carried 
through  without  the  slightest  nerve-muscular  response  on 
the  part  of  the  patient. 

PROSTATE 
The  special  sources  of  danger  in  prostatectomy  are  the 
anesthetic,  shock,  and  hemorrhage.     As  a  result  of  many 
efforts  to  diminish  these  dangers,  the  following  method  has 

158 


A.NOCI-ASSOCIATION    IN    GENITO-URINARY    OPERATIONS  159 

been  evolved  by  means  of  which  the  operation  may  be  per- 
formed without  hesitancy  upon  patients  who,  because  of 
their  age  or  because  of  diminished  vitality,  have  been  con- 
sidered bad  operative  risks.  Patients  undergoing  a  prosta- 
tectomy performed  by  this  technique  are  not  only  free  from 
shock,  but  are  in  splendid  condition  to  combat  any  other 
untoward  influence  that  may  arise  during  convalescence. 

As  in  bladder  operations,  the  preliminary  dose  of  morphin 
and  scopolamin  is  followed  by  the  injection  through  a  cathe- 
ter into  the  bladder  of  »>()  or  90  c.c.  of  a  .">  per  cent,  solution 
of  alypin.  The  catheter  is  clamped  and  allowed  to  remain. 
The  technique  described  for  bladder  operations  is  followed 
until  the  prostate  is  exposed  intravesically  (Fig.  36).  The 
bladder  mucosa  of  the  projecting  prostate  is  infiltrated  with 
novocain,  and  a  deep  infiltration  is  made  along  the  edge  of 
the  capsule  Fig.  37).  With  careful  and  most  gentle  manipu- 
lations  U"  prostate  is  enucleated  with  the  finger  Fig.  38  . 
Not  "how  rapidly"  but  "how  carefully"  is  the  slogan.  Nar- 
row -trip-  of  gauze  .Hi'  packed  along  the  catheter  above 
the  mucous  membrane  so  that  the  raw  surfaces  of  the  cap- 
sule are  brought  in  apposil  ion  a  procedure  which  effect  ively 
prevents  hemorrhage  (Fig.  39).  The  two  ends  of  the 
urethra  also  are  broughl  closely  together  by  this  mean-  so 
that  a  continuous  funnel-shaped  mucous  membrane  re- 
sults   a  most  important  factor. 

At  the  close  of  the  operation,  the  color  of  the  patient 
will  be  good;  t  he  pulse  and  respiration  will  nol  be  increased, 

in  fact,  may  lie  even  lower  than  before  the  operation.      The 

patient  will  rest  comfortably,  will  be  free  from  nausea,  can 
take  water  easily,  and  :i  speedy,  uninterrupted  convalescence 

may   be  looked    for. 


160  ANOCI-ASSOCIATION 

KIDNEY 

The  approach  to  the  kidney  is  through  tissues  which,  in 
their  evolutionary  development,  have  not  been  subjected 
to  environmental  trauma;  consequently  they  are  not  so 
richly  endowed  with  nociceptors  as  are  the  tissues  of  the 
anterior  abdominal  wall.  There  are,  however,  a  sufficient 
number  of  nociceptors  in  the  skin  and  muscles  to  make 
their  infiltration  advisable. 

Parts  of  a  kidney  operation  in  which  the  anoci  technique 
is  urgently  demanded,  however,  are  the  separation  of  the  ad- 
herent kidney  from  its  attachments  and  its  delivery  into 
the  wound. 

The  first  and  most  important  requirement  in  an  operation 
upon  the  kidney  is  an  ample  incision.  An  ample  incision 
with  the  muscular  relaxation  obtained  through  anoci-asso- 
ciation  makes  clearly  visible  the  lines  of  adhesion. 

The  adhesions  should  be  divided  by  sharp  dissection  until 
the  line  of  cleavage  is  reached.  In  the  case  of  a  suppurating 
kidney,  the  line  of  easy  cleavage  is  on  the  rear  surface  of  the 
kidney  itself  underneath  the  thickened  capsule.  In  a  tu- 
berculous kidney,  however,  the  separation  must  be  made 
outside  the  capsule  in  order  that  the  wound  may  not  be  in- 
fected with  tubercle  bacilli.  Old  tuberculous  kidneys  pre- 
sent dense  and  strong  adhesions,  most  of  which,  however, 
may  be  readily  divided  by  sharp  knife  dissection. 

The  easier  kidney  operations  on  good  risk  subjects  are 
relatively  safe  by  even  the  most  nocuous  technique;  but 
the  protection  of  anoci-association  is  urgently  needed  by 
the  patient  reduced  by  hemorrhage  or  infection,  or  the  func- 
tional power  of  whose  kidney  has  been  perilously  reduced 
by  any  cause. 


ANOCI-ASSOCIATION    IN    GENITO-URINARY    OPERATIONS      101 


Fig    34      Bladder  Operations.     Infiltration  op  Skin  with  Novocain. 


i  i 


ANOCI-ASSOCIATION    IX    GENITO-UBINARY    OPERATIONS     163 


I  to,  35      Bladder  Operations      Infiwration  01   r>i  \m>i  a  \\  mi,  Bj  pori 

i  »ri  NINO. 


ANOCT-ASSOCIATION    IN    GENITOURINARY   OPERATIONS      165 


1  i,,.   36.     Prostatectomy,     [ntra vesical    Exposurj    oi     rai     Pbostati 


ANOCI-ASSOCIATION    IN    GENITOURINARY    OPERATIONS.    167 


In,   . ; ,      Pro  rATECTOMY,     Infiltration  oi  Capsule  01  Prostati  Gland 

Bi  i or]  i;i  \i<>\  \i 


ANOO-ASSOCIATION    IN    GENITOURINARY    OPERATIONS     169 


In..    38.     I'ikm  \i  i  (  roMY.    Caviti    Lest    \i  rea    Enucleation    01     ran 

Probi  \  1 1 


AXOCI-ASSOCIATIOX    IN    GENITOURINARY    OPERATIONS      171 


Fig.  39      Prostatbctomi      '  I  u  ei    Packing  bt  which  the  Raw  Surfaces 

ill       |  Ml      (   '  \|'~l    I.I        \|(|       I'.Knl    ..II  |      IN     A.PPOB]  I  HiN. 


CHAPTER  XII 
TWO-STAGE  OPERATIONS 

Cancer  of  the  Rectum.     Cancer  of  the  Stomach.     Cancer  of  the  Uterus. 
Cancer  of  the  Larynx.     Cancer  of  the  Tongue.     Summary. 

Certain  conditions — cancer  especially — may  demand  a 
two-stage  operation  because  the  patients  are  too  much  weak- 
ened to  endure  at  one  blow  the  stress  of  tin1  operation  and 
the  subsequent  physiological  adjustment.  As  Lilienthal 
has  pointed  out,  this  is  especially  true  of  patients  weakened 
by  cancer  of  the  rectum,  stomach,  large  intestine,  uterus, 
larynx,  or  tongue. 

A  comparison  of  many  two-stage  operations  carried  out 
under  the  nocuous  technique  with  those  performed  under 
anoci-associali<>n  demonstrates  quite  clearly  several  funda- 
mental points. 

The  experience  of  the  anociated  patient   in  the  firsl  stage 
of  the  operation  is  so  much  easier  than  lus  anticipations 
his  loss  of  \itality  and  change  of  nervous  threshold  are  so 
slight     thai  he  is  emboldened  to  meet  the  Becond  stage  with 
equanimity.     It  das  been  gratifying  to  find  thai  the  second, 

Usually    the    major,    stage    causes    no    more    disturbance 

sometimes  less  even  than  followed  the  preliminary  opera- 
tion. For  example,  it  lias  been  OUT  experience  thai  in  the 
firsl  of  the  two  stages  of  a  laryngectomy  the  variations  of 
pulse  and  temperature  were  more  marked  than  in  the  second 
stage. 

173 


174  ANOCI-ASSOCIATION 

CANCER  OF  THE  RECTUM 
In  cancer  of  the  rectum,  the  preliminary  colostomy  pre- 
pares the  way  splendidly  for  the  major  operation.  In  this 
operation  the  energy  of  the  patient  is  conserved,  not  only 
by  the  novocain  blocking  of  the  tissues  to  be  divided  but 
also  by  the  complete  hemostasis  and  the  sharp  dissection. 

CANCER  OF  THE  STOMACH 

In  cancer  of  the  stomach,  unless  the  risk  be  good,  gastro- 
enterostomy is  performed  at  the  first  operation,  resection 
being  performed  as  soon  as  the  nutritional  balance  is  assured 
— usually  in  ten  days  or  two  weeks.  In  starved  cases  of  gas- 
tric ulcer  Professor  von  Eiselsberg's  method  is  excellent — a 
jejunostomy  is  first  performed  under  local  anesthesia,  the  final 
operation  being  delayed  until  a  safe  vital  margin  has  been 
attained  by  feeding.  Gastroenterostomy  alone  gives  a  rather 
light  morbidity  as  compared  to  gastrectomy,  as  the  wound  is 
not  as  extensive  as  in  the  latter  operation,  and  the  physio- 
logic and  anatomic  readjustment  is  readily  made.  This 
readjustment  being  accomplished,  the  gastric  resection  is 
performed  with  a  wider  margin  of  safety.  By  lessening  the 
amount  of  the  trauma  inflicted  at  one  seance,  and  by  re- 
lieving the  patient  from  the  burden  of  extensive  wound 
recovery  simultaneous  with  the  functional  adjustment,  the 
probability  of  recovery  is  far  greater  than  when  one  mas- 
sive chance  is  taken. 

An  unexpected  advantage  in  the  two-stage  operation  for 
gastrectomy  is  illustrated  in  a  recent  case.  A  large  pyloric 
mass  was  diagnosed  as  cancer  by  an  able  internist  and  at 
the  preliminary  operation,  even,  was  considered  to  be  cancer. 
At  the  second  operation  which,  on  account  of  the  extreme 
emaciation  and  weakness  of  the  patient,  was  delayed  for  an 


TWO-STAGE    OPERATIONS  175 

unusually  long  time,  it  was  found  that  the  large  solid  mass 
at  the  pylorus  had  disappeared  as  if  by  magic.  To  make 
certain  that  no  cancer  existed  at  the  base,  the  Rodman  opera- 
tion was  performed  in  this  case — a  simple,  almost  a  minor, 
operation.  The  pathologist  reported  that  there  was  no 
trace  of  cancer — indeed  that  nothing  abnormal  could  be 
found  excepting  a  little  scar  tissue.  The  second  operation 
caused  but  slight  disturbance.  Had  the  entire  operation 
been  performed  at  the  first  stage,  not  only  would  a  great 
hazard  have  been  taken  as  to  life,  but  also  a  needless  opera- 
tion would  have  been  performed. 

Another  two-stage  operation  for  cancer  of  the  stomach 
u.i-  performed  on  a  patient  72  years  of  age  whose  case  had 
been  given  up  as  hopeless.  She  herself  insisted  on  an  oper- 
ation and  was  brought  to  the  hospital  in  an  ambulance. 
She  was  given  a  transfusion  of  blood  and  passed  through  a 
two-stage  operation  with  great  ease,  enduring  the  second 
operation  more  easily  than  the  first.  Four  years  have 
passed  since  the  operation  and  the  patient  is  today  bright 
and  well  al  76. 

We  are  convinced  thai  the  present  high  mortality  which 
attends  resections  of  the  stomach  in  all  clinics  can  be 
diminished  more  than  one-half  by  anod-association,  and.  in 
the  case  of  handicapped  patients,  by  two-stage  operations. 

CANCER  OF  THE  UTERUS 

Many  surgeons  n"\\  believe  that  the  besl  method  for  per- 
forming hysterectomy  for  cancer  is  by  dissection  with  the 
cautery,  and  t  lie  arguments  for  this  method  are  well  founded. 
Whatever  met  hod  is  used,  however,  in  our  opinion  the  opera- 
tion should  be  performed  in  t\\<>  stages  to  avoid  the  fatal 
implantation  <»i  cancer  cells  in  the  field  of  operation. 


176  ANOCI-ASSOCIATION 

In  cancer  of  the  cervix,  at  the  first  operation  every  vestige 
of  the  growth  is  destroyed  by  heavy  cautery  irons  which 
carry  enough  heat  to  coagulate  protoplasm  well  beyond  the 
parts  in  contact  with  them — coagulation  not  eschar  is  the 
aim.  After  the  local  cancerous  growth  is  destroyed,  the 
vagino-cervical  attachments  are  severed  with  a  dissecting 
cautery,  in  order  that  all  blood-vessels  running  from  the 
vagina  to  the  uterus  may  be  divided.  After  this  complete 
wide  destruction  of  the  cancer-bearing  cervix,  so  little  uter- 
ine tissue  is  present  in  the  vagina  that  complete  vaginal  hys- 
terectomy, even  of  the  Schuchardt  type,  could  not  well  be 
performed.  Even  should  this  be  possible,  unless  it  can  be 
completely  accomplished  by  means  of  a  cautery,  there  should 
be  an  interval  of  at  least  a  day  before  the  completion  of  the 
hysterectomy.  This  interval  is  required  to  ensure  the  death 
by  anemia  of  every  detached  cancer  cell.  The  vagina, 
instruments,  gloves, — everything  in  the  neighborhood  of  the 
cancer, — may  harbor  cancer  cells.  During  the  interval  the 
vagina  is  lightly  packed  with  large  sponges  saturated  with 
alcohol.  On  the  following  day  abdominal  hysterectomy  is 
performed. 

In  this,  as  in  all  two-stage  operations,  the  use  of  nitrous- 
oxid-oxygen  plays  a  most  benevolent  role.  The  patient  has 
no  distressing  experience  in  going  under  this  anesthetic  and, 
therefore,  returns  for  the  larger  operation  in  a  reassured 
state  of  mind. 

No  nerve  blocking  is  used  in  the  preliminary  vaginal 
operation  because  in  a  cancer  field  whose  boundaries  are  so 
uncertain  as  are  those  of  cancer  of  the  cervix  there  is  risk 
that  the  cancer  cells  may  be  reimplanted  by  the  needle. 

In  the  second  operation  the  anoci-association  technique 


TWO-STAGE    OPERATIONS  1  <  7 

varies  in  several  important  particular-  from  thai  described 
for  the  removal  of  benign  tumors.  First,  only  the  abdom- 
inal wall  is  infiltrated;  second,  as  the  dissection  must  be 
carried  down  against  the  pelvic  wall,  and  as  the  widest 
possible  excision  of  the  parametrium  is  required,  a  wide 
field  of  exposure  is  accessary.  The  intestines  are  kept  out 
of  the  pelvis  by  gentle  retraction  with  gauze  pads.  To  se- 
cure the  needed  relaxation  at  this  stage  of  the  operation,  it 
may  be  necessary  to  add  some  ether  to  the  oitrous-oxid- 
oxygen. 

By  the  following  technique  opportunity  is  given  for  ample 
dissection  and  yet  it  is  possible  for  the  patient  to  be  carried 
through  mainly  under  nitrous-oxid-oxygen  anesthesia. 

With  the  patient  in  the  Trendelenburg  position,  the  ab- 
dominal wall  is  thoroughly  infiltrated  with  novocain  and 
an   ample    incision    made.      While    going    through    the    wall 

ether  is  added  to  the  oitrous-oxid-oxygen  to  secure  the  neces- 
sary relaxation  for  the  next  step.     The  relaxed  abdominal 

wall  is  raised  and  by  mean-  of  large  moist  gauze  pads  of  the 
Mo\  nih.-iii  type,  the  intestines  arc  gently  pressed  out  of  the 
pelvis.  A-  soon  as  the  pelvis  is  clear  and  ha-  been  ade- 
quately protected  again-t  the  return  of  the  intestines  during 
the  pelvic  dissection,  ether  i-  discontinued  a-  oitrous-oxid- 
oxygen  alone  i-  sufficient  for  the  remainder  of  the  opera- 
tion. Local  anesthesia  is  not  used  within  the  pelvis  be- 
cause of  the  danger  "I  piercing  some  cancer  tissue  with  the 
needle.  The  tissues  are  protected  by  anoci-strategy,  how- 
ever. The  uterus  is  not  pulled  up  out  of  the  pelvis,  hut 
the  surgeon  goes  down  into  the  pelvis  to  the  uterus  so  thai 
its  fundus  need  not  he  grasped  by  any  instrument.  The 
clamps  "ti  the  broad  ami  round  Ligaments  are  sufficient  for 
12 


178 


ANOCI-ASSOCIATION 


the  required  orientation  of  the  uterus.  Throughout  the  dis- 
section sharp  knife  division  or  the  dissecting  cautery  only  is 
used.  The  course  of  the  ureter  is  easily  seen,  and  the  sepa- 
ration from  the  bladder  is  readily  made.  When  communi- 
cation with  the  vagina  is  made  at  any  point,  the  critical 
part  of  the  operation  is  past.  Only  vaginal  drains  are  used 
(Fig.  40). 


Bee-t<s 

70 

80 

90 

100 

no 

120 

Ether 

Na.0 

AnocM. 

The  Pulse. 
Each  heavy  line  represents  the  average  5  p.  m.  pulse-rate  of  ten  patients  during  the  first  four 

days  after  operation. 

Fig.  40. — Comparative  Clinical  Results  of  Consecutive  Abdominal 
Hysterectomies  Performed  under  Ether  Anesthesia,  under  Nitrous- 
Oxid-Oxygen  Alone,  and  under  Complete  Anoci-association. 

In  this  two-stage  operation  it  is  especially  interesting  to 
note  the  conservation  of  the  patient's  vitality. 

In  cancer  of  the  fundus  of  the  uterus  a  different  plan  is  fol- 
lowed. The  cervical  canal  is  seared  by  pressing  into  it 
one  of  Ochsner's  heavy  cautery  irons.  The  cervix  is  then 
tightly  closed  by  through  and  through  stitches  with  strong 
catgut.  The  sutures  are  tied  and  long  ends  are  left  to 
serve  as  tractors.  A  vaginal  hysterectomy  is  then  performed. 
The  cervix  is  freed  by  means  of  either  a  dissecting  cautery 
or  a  knife,  the  tissue  being  divided  very  gently  until  the 
broad  and  round  ligaments  are  reached.  By  this  technique 
the  field  is  well  safeguarded  against  cancer  implantation 
and  there  is  but  little  shock. 


TWO-STAGE    OPERATIONS  179 

Since  their  realization  and  application  of  the  underlying 
principles  involved,  the  authors  have  not  seen  a  single  death 
from  shock  or  from  exhaustion  in  any  operation  for  cancer 
in  the  pelvic  organs. 

CANCER  OF  THE  LARYNX 

The  value  of  the  two-stage  operation  is  perhaps  best  il- 
lustrated by  the  two-stage  operation  for  cancer  of  the  larynx. 
in  the  firsl  stage  of  which,  by  means  of  a  preliminary  gauze 
packing,  thai  very  vulnerable  area,  the  mediastinum,  and 
the  region  along  the  deep  vessels  and  the  trachea  and  esoph- 
agus are  amply  prepared  to  resist  the  inevitable  exposure 
to  infection  when  the  larynx  is  removed.  This  technique 
eliminates  the  great  danger  of  mediastinal  infection  which, 
after  pneumonia,  has  been  the  most  fatal  result  of  laryn- 
gectomy. The  explanation  of  the  characteristic  painless, 
tedious  and  fatal  course  of  mediastinal  abscess  is  probably 
found   in   the  fact    that    this  region  of  the  body   has  always 

been  protected  from  wounds  by  the  bony  chesl  wall.  Being 
closed  to  wound-  through  the  vast  periods  of  man's  evolu- 
tion, it  has  been  closed  likewise  to  infection.  The  tissue 
of  this  protected  region,  therefore,  has  not  been  endowed 
with  the  elements  required  to  efficiently  meet  and  over- 
come infection,  a-  have  been,  for  example,  the  peritoneum 
and  the  external  parts  of  the  body.  In  view  of  this  fact. 
we  musl  guard  this  helpless  territory  with  special  care,  by 
means  of  preoperative  protection.  An  ideal  defense  is 
made  by  opening  and  packing  the  deep  plane-  of  the  base  of 
the  neck,  and,  ;it  the  same  seance,  makings  l"\\  tracheot- 
omy. By  this  means  the  mediastinum  is  put  under  strong 
guard,  :ind  ;it  the  same  time  the  bier  technique  of  the  laryn- 
gectomy i-  measural >ly  reduced. 


180 


ANOCI-ASSOCIATION 


The  danger  of  vagitis  also  may  be  eliminated  if  the  dis- 
section be  carried  on  one  side  of  the  larynx  all  the  way  to 
the  upper  margin  of  the  field  of  final  operation,  this  terri- 
tory being  packed  with  iodoform  gauze  just  as  the  deep 
planes   of   the   neck   are  packed.     By   this   procedure   one 


Fig.  41. — Laryngectomy.  Schematic  Drawing  to  Illustrate  the 
Method  of  Packing  the  Lateral  Planes  of  Neck  with  Iodoform 
Gauze  at  Preliminary  Operation. 

vagus  must  take  the  brunt  of  exposure  and  adjustment  be- 
fore the  larynx  is  removed.  By  the  time  the  laryngectomy 
is  done  this  vagus  will  be  readjusted  and  ready  to  resume 
its  function  in  case  it  be  affected  at  all,  and  so  the  heavy  on- 


TWO-STAGE    OPERATION- 


1S1 


I  to     12.     Laryngectomy.     Infimtiation    01    Skin    with    Novo  w\. 


TWO-STAGE    OPERATIONS 


183 


fQ 

U 


I  io,   13.     Laryngectomy.     Infiltration  "i    Fascia   with   Novocain. 


TWO-STACK    O I' K RATIONS 


185 


I  i...     II.     Labynoei  roMY. 


NOVOCAINIZING     i  in.     \  i  i;\  i  -i  NDINGfl    01 

Th  \'iu   \. 


TWO-STAGE    OPERATIONS  l.S< 

slaught  of  tlie  vagi  upon  the  heart  will  not  be  made  by  both 
vagi  simultaneously.  In  the  case  in  which  one  of  us  tried 
this  plan  it  seemed  to  be  completely  effective  (Fig.  41). 

The  second  stage — the  excision  of  the  larynx — is  safely 
and  easily  accomplished.  Each  division  of  skin,  sub- 
cutaneous tissues,  platysma,  and  mucosa  is  preceded  by  a 
thorough  infiltration  with  novocain.  Reflex  inhibition  of 
the  heart  and  respiration  through  mechanical  stimulation 
of  the  superior  laryngeal  nerves  may  be  absolutely  prevented 
by  the  hypodermic  administration  of  ,  ',  „  gr.  atropin  (adult 
dose)  before  the  operation  and  during  the  operation  by  the 
local  use  of  novocain  applied  either  by  a  spray  or  hypo- 
dermically.  Laryngectomy  is  usually  followed  by  a  brisk 
local  reaction ;  but  since  the  mediastinum  has  been  protected 
by  the  previous  gauzc^  packing,  and  the  bronchopulmonary 
tract  has  been  given  a  special  defense  by  the  preliminary 
tracheotomy,  the  patienl  is  well  equipped  to  meet  the  new 
condition    Figs.  12   15  . 

Of  thirty-tour  Laryngectomies,  twenty-eight  have  been 
performed  in  two  stages  with  but  a  -ingle  death. 

CANCER  OF  THE  TONGUE 

In  operations  for  cancer  of  the  tongue  two  difficult  prob- 
lems ti hi- t  be  met,  the  immediate  surgical  risk  and  the  possi- 
bility of  permanent  cure.  The  principal  immediate  danger 
is  pneumonia  from  inhalation  of  infection  from  the  Held  of 
operation,  while  there  is  also  danger  from  the  exhaustion 
which  ia  :i  result  of  the  diminished  ingestion  of  food  and  the 
prolonged  endurance  of  the  disease. 

To  ensure  8  permanent  cure  not  only  is  the  cancer  to  be 
removed  but  ;ill  of  the  glands  of  the  neck  must  be  completely 


188 


ANOCI-ASSOCIATION 


excised  whether  they  be  enlarged  or  not.  If  both  of  these 
operations  be  performed  at  the  same  seance,  then  the  patient 
may  go  to  the  ground  because  he  is  unable  to  bear  the  bur- 
den of  the  diminished  nutrition  and  the  soreness  over  so 


Fig.  45. — Laryngectomy.     Schematic  Drawing  Showing  Arrangement 
of  Tube  through  which  the  Inhalation  Anesthesia  is  Administered 

AND  ALSO  THE  SHOEMAKER'S  StITCH  USED  IN  CLOSING  PHARYNGEAL  OPEN- 
ING. 

large  a  field  as  the  mouth  and  neck  and  the  inevitable  infec- 
tion in  the  mouth.  The  possibility  of  a  permanent  cure  de- 
pends also  on  the  prevention  of  the  immediate  implantation 
of  cancer  cells  in  the  mouth  at  the  time  of  the  operation.  If 
the  cancer  be  not  large,  no  cutting  operation  whatever  is 


TWO-STAGE    OPERATIONS  189 

made  hut  with  the  cautery  all  of  the  disease  in  the  mouth  is 
destroyed.  If,  however,  the  growth  be  extensive,  it  is  besl 
on  one  day  to  cauterize  the  field  of  the  disease  and  on  the 
following  day  after  the  cancer  cells  have  died  of  starva- 
tion, to  excise  the  entire  cancer  field  in  the  mouth.  After 
the  patient  has  well  recovered  from  the  mouth  operation 
and  is  able  to  take  nourishment  satisfactorily,  the  final  op- 
eratioE  the  excision  of  the  glands  in  the  neck — can  be  per- 
formed without  great  inconvenience  to  the  patient. 

In  addition  to  the  lessened  risk  of  the  extension  of  the 
cancer,  the  two-stage  operation  lessens  also  the  danger  of 
infection,  for  when  the  whole  operation  is  performed  at  one 
seance  the  neck  is  so  sore  that  the  patient  is  almost  certain 
to  inhale  infection  from  the  mouth  directly,  whereas  if  the 
neck  be  normal  the  patient  i->  able  to  stand  up,  to  move 
about,  to  spil  out  the  inhalations  and  thus  to  protect  his 
Lungs  againsl  the  infection. 

SUMMARY 
The  two-stage  operation  under  anocwMSOciation  gives 
the  surgeon  In-  maximum  opportunity  for  Lessening  the  op- 
erative mortality  rate  in  many  of  the  gravest  surgical  risks. 
Thus  we  may  triumph  over  surgical  difficulties  by  strate- 
gically dividing  our  forces.  In  our  own  personal  experience 
in  these  formidable  operations  for  cancer,  the  mortality 
rate  has  already  been  diminished  one-half. 


CHAPTER  XIII 

ANOCI-ASSOCIATION  IN  TREATMENT  OF 
EXOPHTHALMIC  GOITER 

Every  one  will  agree  that  a  technique  that  can  carry  an 
advanced  exophthalmic  goiter  case  through  an  operation 
without  increasing  the  pulse-rate  can  all  the  more  readily  do 
as  much  in  any  other  operation.  In  fact,  it  was  in  large 
measure  the  study  of  the  preoperative  and  postoperative 
course  of  cases  of  Graves'  disease  which  led  to  the  enuncia- 
tion of  the  kinetic  theory  of  shock  and  the  development  of 
the  shockless  operation. 

Graves'  disease  is  not  a  disease  of  a  single  organ,  nor  is  it 
the  result  of  some  fleeting  cause,  but  it  is  a  disease  of  the 
motor  mechanism  of  man,  the  mechanism  by  which  physical 
action  is  being  produced  and  the  emotions  expressed.  Phy- 
logeny  as  well  as  ontogeny  must  be  called  to  account  for  its 
existence,  though  the  final  exciting  cause  may  be  a  stimu- 
lating emotion,  an  infection,  autointoxication,  or  any  other 
stimulus  of  the  kinetic  system,  as  a  result  of  which  a  patho- 
logical interaction  is  established  between  the  brain  and  the 
thyroid.  This  pathologic  interaction  may  be  broken  by 
diminishing  the  thyroid  output,  thus  allowing  the  brain  to 
regain  its  normal  control  of  the  mechanism ;  or  by  securing 
physical  rest  by  which  the  brain  will  fast  regain  its  normal 
control  and  which  in  time  will  cause  the  return  of  the  thy- 
roid to  its  normal  activity. 

190 


ANOCI-ASSOCIATION    IN   EXOPHTHALMIC    GOITER         191 

A  searching  inquiry  into  the  past  history  of  a  patient 
with  (oaves'  disease  will  frequently  elicit  the  fact  that  he 
has  undergone  some  emotional  experience,  often  so  deeply 
disturbing  in  its  nature  that  it  has  become  a  dominant  emo- 
tional stimulant,  absorbing  attention  during  the  day  and 
disturbing  sleep  at  night.  The  constant  recurrence  of  this 
evil  stimulus  is  attended  by  an  increase  of  all  the  emotional 
phenomena,  so  that  gradually  a  state  is  reached  in  which 
the  effects  of  the  constantly  present  stimulus  remain  un- 
changed— the  eyes  protrude,  the  body  trembles,  the  facies 
of  terror  is  present,  the  thyroid  is  permanently  enlarged,  the 
entire  emotional  (motor)  mechanism  being  involved  (Fig.  46). 

In  such  a  state  any  excitation  which  might  produce  slight 
apprehension  in  a  normal  individual  becomes  an  overwhelm- 
ing stimulus.  In  patients  with  Graves'  disease,  the  mere 
proposal  that  an  operation  be  performed  becomes  a  patho- 
logical excitation  which  may  so  increase  the  disease  that  the 
patient  is  even  less  able  than  before  to  make  up  his  mind  to 
submit  to  adequate  treatment.  On  all  sides  the  patient  is 
besei  by  vicious  circles,  by  pathological  interactions.  The 
ideal  plan  of  approach,  therefore,  is  to  assure  the  patient 
that  his  malady  is  curable,  that  treatment  can  besl  be  ad- 
ministered in  a  hospital;  that  unoperat ive  measures  will 
firsl  !•»•  tried,  bul  thai   if  they  prove  inadequate,  a  simple 

Operation  will  be  performed;  that    it  will  be  best  to  leave  the 

final  decision  a-  to  the  advisability  of  an  operation  to  his 
medical  adviser;  and  that,  since  even  the  discussion  of  an 
operation  is  both  unpleasant  and  injurious,  it  will  be  besl 
not  to  open  the  subject  again. 

If  tin'  patient,  as  is  usually  the  case,  consent  t>>  leave  the 
whole  matter  i<»  the  judgment  of  the  physician,  the  way  is 


192  ANOCI-ASSOCIATION 

opened  for  the  most  effective  treatment  which  in  our  judg- 
ment has  ever  been  proposed  for  exophthalmic  goiter;  that 
is,  ligation  or  excision  under  the  protection  of  anoci-associa- 
tion. 

For  several  days  the  anesthetist  with  the  paraphernalia 
for  the  administration  of  nitrous-oxid-oxygen  administers 
to  the  patient  fictitious  "inhalation  treatments."  On  the 
morning  of  the  operation,  which  is  performed  in  one  of  the 
favorable  phases  of  the  many  cycles  of  this  disease,  the 
hypodermic  injection  contains  morphin  and  scopolamin; 
nitrous  oxid  is  added  to  the  oxygen  "inhalation,"  and  the 
patient  falls  asleep  in  bed  without  realizing  that  the  first 
step  in  the  operation  is  being  taken.  The  anesthetized 
patient  is  transported  to  the  operating  room,  where  the 
operative  field  is  prepared.  In  the  operation  itself  each 
division  of  tissue  is  preceded  by  the  infiltration  of  novocain, 
and  sharp  dissection  and  gentle  manipulations  are  employed 
throughout.  In  grave  cases  quinin  and  urea  hydrochlorid 
may  be  injected  into  every  part  of  the  operative  field  before 
the  wound  is  closed,  though  the  need  for  this  protection  may 
be  neutralized  by  the  employment  of  so  gentle  and  strategic 
a  technique,  that  a  minimum  amount  of  trauma  is  caused 
and  the  postoperative  protection  of  quinin  and  urea  may  not 
be  needed. 

The  patient  is  kept  under  anesthesia  until  he  has  returned 
to  his  room,  which  has  been  restored  to  its  condition  when 
the  administration  of  the  anesthetic  was  started.  In  the 
course  of  the  cycle  from  his  room  to  the  operating  room  and 
to  his  return,  the  patient's  brain  has  received  no  activating 
stimuli  and  no  record  of  the  operation  has  been  written  upon 
either  the  conscious  or  the  subconscious  brain. 


AXOCI-ASSOCIATIOX    IN    EXOPHTHALMIC    GOITER  193 


I  i'..  Mi.    T>  picalCa8eoi  Exophthalmic  Goiter  Showing  Chabacteristk 

I'  M   ||;s. 


L3 


ANOCI-ASSOCIATION    IX    EXOPHTHALMIC    OOITER 


195 


By  this  technique  the  scope  of  the  operation  is  greatly 
increased,  and  the  lobe  can  be  safely  removed  from  any  pa- 


Fig.  17.    Thyroidectomy.     Infiltration  of  Skin. 

tient    whose  condition   can   endure   the   metabolic  influence 

of  the  withdrawal  of  so  much  active  "land  tissue.  In  cases 

in  which  the  excision  of  a  lobe  is  contraindicated,  it  is  best 


Fiq.  48     Thyroidectomy.    Infiltration  of  Muscli  before  Division. 

to  ligate  one  or  both  pole-,  excising  the  lobe  later,  if  it  be 
necessary.  Ligation  is  performed  without  removing  the 
patienl  from  hie  bed.     Nitrous-oxid-oxygen  may  or  may  not 


196 


ANOCI-ASSOCIATION 


be  administered,  but  the  brain  is  always  protected  by  a  com- 
plete novocain  infiltration. 

As  for  the  technique  of  the  excision  itself;  the  transverse 
incision  should  be  sufficiently  ample  to  expose  the  gland 
to  its  lateral  border  (Fig.  47).  The  important  part  of  the 
dissection  may  thus  be  in  full  view  without  more  than  nom- 
inal retraction  of  the  muscle.  The  operation  should  be 
so  bloodless  throughout  that  the  lymphatic  vessels  can  be 
everywhere  seen  and  identified.     This  may  be  accomplished 


Fig.    49. — Thyroidectomy. 


Bloodless  Division   of  Muscles  Between 
Clamps. 


if  every  blood-vessel  is  clamped  twice  and  divided  between  the 
forceps  (Figs.  48  and  49).  The  field  will  then  always  be 
translucent,  and  being  thus  controlled,  the  dissection  is 
carried  entirely  on  the  capsule  itself.  The  hoarse  voice  which 
used  to  be  a  frequent  sequel  to  thyroidectomy  has  been 
largely  eliminated  by  cdways  picking  up  tissue  parallel  to 
the  larynx  and  trachea,  and  never  at  right  angles  to  them.  If, 
in  the  translucent  field,  the  Halsted  forceps  are  applied 
always  parallel  with  and  closely  against  the  capsule  of  the 
gently  retracted  gland,  no  paralysis  of  the  vocal  cord  will 
follow,  while  the  parathyroid  will  rarely  if  ever  be  en- 
dangered nor  will  its  blood  supply  be  disturbed. 


ANOCI-ASSOCIATION    IX    EXOPHTHALMIC    GOITER 


19" 


The  surgeon  also  must  protect  himself  from  a  certain 
psychic  phase  which  is  apt  to  develop  in  difficult;  goiter 
operations  and  which  corresponds  to  the  "break"  of  the 
pointer  dog  when  he  "rushes  the  covey."  As  the  surgeon 
follows  a  trying  and  teasing  path  around  a  baffling  lower 


Bea.t  5 

70            801          90 

100 

110 

120 

Et^er. 

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The  Pulse. 
Bach  heavy  line  represents  the  average  5  p.  u.  pulse-rate  oi  ten  patients  during  the  tirsi  four 

daj  a  after  operation. 

I'ii,.  ."id.  -Comparative  Clinical  Results  of  Consecutive  Thyroideo 
roMiES  I'lKininiKi)  under  Ether,  under  Nitrous-Oxid-Oxtgen  Alone, 
and  dnder  Complete  Anod-association. 


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Fiq.  51.    Chart  Illustrating  Prote n  Afforded  by  usi  01    Lnoct-osse- 

ciation  i\  Tin  R<  hih.<  r<  >\n . 

The  patient's  brain  received  neither  traumatic  aor  psychic  Btimuli  from  the 
be  was  anesthetized  in  bed  until  she  returned  again  From  the  operating- 
room.     Her  pulse-rate  fell  slightly  during  the  operation.   <  »n  the  other  ha  ml, 
the  psychic  strain  undergone  by  the  patient's  sister  while  the  operation  was 
being  performed  caused  her  pulse-rate  to  rise  to  124. 


border  where  now  and  then  a  small  vein  breaks  and  momen- 
tarily veils  the  field,  he  will  again  and  again  be  tempted  to 
rush  the  operation,  thus  Losing  his  technical  control  of  the 
field.     To  succumb  to  this  temptation  is  to  courl  disaster. 


198  ANOCI-ASSOCIATION 

By  the  control  of  a  translucent  field,  by  rigidly  making 
all  tension  parallel  and  close  to  the  gland  and  by  sharp  knife 
dissection  throughout,  every  drop  of  the  patient's  blood  is 
conserved;  the  parathyroids  are  left  unimpaired;  the  voice 
is  unaffected;  the  wound  may  be  closed  without  drainage; 
the  local  field  is  but  slightly  injured  and  the  trachea  and 
larynx  are  deprived  of  none  of  their  protective  tissue  cover- 
ing (Figs.  50  and  51). 

The  benefits  of  the  operation  do  not  end  with  the  imme- 
diate results.  The  postoperative  hyperthyroidism  is  pre- 
vented or  minimized  and  the  later  clinical  results  are  as  much 
improved  as  is  the  immediate  postoperative  condition. 

When  a  case  of  Graves'  disease,  which  is  not  under  sur- 
gical treatment,  is  subjected  to  a  severe  psychic  shock,  to 
a  heavy  nervous  strain,  or  to  intense  worry,  the  disease  may 
be  aggravated  for  weeks  or  months  and  not  infrequently 
death  results.  The  evil  effects  of  facing  the  ordeal  of  oper- 
ation are  not  only  seen  immediately  but  are  perpetuated  for 
days,  weeks  or  months  by  their  frequent  recall.  From  this 
handicap  the  anociated  patient  is  free  and  by  so  much  is  his 
convalescence  speeded  on  its  way. 

A  comparison  of  the  records  of  the  cases  of  exophthalmic 
goiter  operated  upon  at  Lakeside  Hospital  shows  in  28  con- 
secutive ether  cases  an  average  increase  of  25  beats  in  the 
pulse-rate  in  the  first  twenty-four  hours  after  operation  and 
of  29.9  beats  during  the  operation;  while  28  consecutive 
anociated  cases  showed  an  average  rise  of  but  3.03  beats  in 
the  first  twenty-four  hours  after  operation  and  a  fall  of 
6.39  beats  during  the  operation. 


CHAPTER  XTV 
ANOCI-ASSOCIATION   IN   OPERATIONS   ON   THE   BRAIN 

The  work  of  Horsley,  Gushing  and  Frazier  amply  confirms 
the  conclusion  from  our  laboratory  experiments  that  there 
are  in  the  brain  no  nociceptors,  the  adequate  stimulation 
of  which  can  produce  exhaustion  of  the  brain-cells.  Local 
anesthesia  therefore  is  not  needed  in  operations  on  the  brain, 
although,  as  in  all  other  operations,  the  environment  of  the 
patient  both  before  and  after  the  operation  should  be  kept 
free  from  nocuous  influences. 

It  is  true  that  injury  of  the  brain  may  interfere  with  the 
vasomotor  or  respiratory  centers  and  cause  collapse  —but 
this  collapse  is  not  surgical  shock.  A  certain  class  of  gravely 
handicapped  patients  may  well  be  considered  in  this  con- 
nection, however.  These  are  the  patients  with  a  pathologic 
intracranial  tension  which  most  commonly  results  from  intra- 
cranial hemorrhage  or  depressed  fractures.  Our  researches 
have  -how  n  that  the  brain  cannot  endure  total  anemia  for 
more  than  from  six  and  one-half  to  eight  minutes.  Our 
first  duty  therefore  is  to  maintain  a  high  pressure  until  the 
pathologic   intracranial    tension    IS   relieved.      If   the   patient 

be  comatose,  or  nearly  so,  no  general  anesthetic  should  be 

used,  but  under  local  anesthesia  an  osteoplastic  Hap  may  be 
turned  down,  or  the  skull  at    leasl    may  be  opened.    Should 

:i  general  anesthetic  be  required,  a  momentary  oitrous-oxid- 

oxygen  anesthesia  may  be  given  as  that  will  not  lower  the 

i  M' i 


200  ANOCI-ASSOCIATION 

blood-pressure.  In  these  cases,  however,  pain  is  an  advan- 
tage as  by  its  primary  stimulation  of  the  brain-cells  it  will 
cause  a  rise  in  blood-pressure.  The  slight  resultant  ex- 
haustion can  be  well  borne  later  after  the  pathologic  intra- 
cranial pressure  is  relieved. 

Many  of  these  head  cases  have  been  killed  by  an  unin- 
telligent technique  intended  for  relief,  but  ineffective  because 
of  the  lack  of  appreciation  on  the  part  of  the  surgeon  of 
the  disastrous  result  of  anemia  of  the  brain  of  even  a  few 
minutes  duration. 

In  operations  for  the  relief  of  trifacial  neuralgia  Frazier's 
method  is  of  great  value.  As  soon  as  the  Gasserian  ganglion 
is  exposed  he  injects  alcohol  into  it,  thus  blocking  nerve  con- 
duction. He  then  dispenses  with  general  anesthesia  as  all 
the  rest  of  the  operation  can  be  carried  on  in  the  field  which 
has  been  completely  anesthetized  by  this  blocking  of  the 
entire  trifacial  nerve. 


CHAPTER  XV 

ANOCI-ASSOCIATION  IN  OPERATIONS  FOR  CANCER  OF 

THE  BREAST 

Very  few  large  operations  produce  less  shock  than  does  an 
excision  of  the  breast.  Every  anoci  precaution  must  he 
taken  in  this  operation,  however,  because  patients  with 
(■.nicer  of  the  breast  may  be  heavily  handicapped  by  long 
illness,  by  overwork  and  worry,  by  age— by  all  the  noci- 
associations  which  accompany  this  disease,  not  the  least  oi 
which  is  the  crushing  fear  of  the  cancer  itself. 

There  are  very  few  nociceptors  in  the  area  of  operation 
beneath  the  skin,  so  but  little  local  anesthetization  is  needed 
in  addition  to  thai  produced  by  the  infiltration  of  the  skin 
along  the  line  of  incision.  If  the  patient  be  not  too  feeble, 
the  entire  operation  may  be  shocklessly  performed  under 
local  anesthesia  alone.  ( >ne  of  the  authors  was  once  greatly 
impressed  byseeing  Dr.Bloodgood  perform  a  In-east  ampu- 
tation under  local  anesthesia  alone  upon  a  feeble,  aged  pa- 
tient. There  was  no  shock  and  the  patient  made  an  easy 
and  good  recovery. 

The  important  point  in  these  operation-  i-  not  the  anes- 
thetic but  the  operative  technique  it-elf.  The  pernicious 
habit  of  sponging  with  rough  gauze  should  be  avoided,  as 
should  the  forcible  extraction  of  the  lymphatic  glands,  and 

the   violent    separati f   the   mammary   glands.     Sharp 

knife  dissection  is  not  only  less  damaging  to  the  tissues,  thus 

•j(  >  i 


202  ANOCI-ASSOCIATION 

favoring  wound  repair,  but  it  makes  it  easier  to  maintain  a 
dry,  clear  field. 

To  minimize  postoperative  pain  and  to  prevent  infection 
from  necrosis  of  the  tissues,  the  skin  surfaces  should  not  be 
pulled  together  with  tight  sutures,  but  to  avoid  tension 
the  field  should  either  remain  open,  skin  grafts  being  made 
to  close  the  surface,  or  the  Rodman  technique  for  making 
skin  flaps  should  be  employed. 


CHAPTER  XVI 

ANOCI-ASSOCIATION  IN  OPERATIONS  ON  THE  EXTREM- 
ITIES    ACCIDENTS 

Amputations.     I  >-tcotomy.     General  Considerations  in  Accident  Cases. 
AMPUTATIONS 

Amputations  are  nearly  always  performed  upon  patients 
seriously  handicapped  either  by  the  acute  shock  which  re- 
sults from  crushing  injuries,  or  by  general  debility  as  in 
cases  of  senile  or  diabetic  gangrene.  Amputations  for  sar- 
comata of  the  bones  are  less  frequently  performed  than  for- 
merly. 

The  general  technique  of  anoci-ussocialton  in  these  cases 
includes  nitrous-oxid-oxygen  anesthesia;  the  progressive 
infiltration  with  novocain  of  the  skin  and  subcutaneous 
tissues;  the  intraneural  anesthetization  of  nerve  trunks; 
the  sharp  division  of  the  soft  parts  to  the  bone:  and 
the  division  of  the  bone  with  a  Gigli  saw.  No  tourniquet 
is  used,  but  all  blood-vessels  are  secured  en  r<>ut<  so  that  a 
dry,  clear  field  is  maintained  throughout.  The  crushed 
tissues  should  be  handled  mosl  gently,  in  fact,  nil  handling 
should  be  <>n  the  distal  side  of  the  field.  In  short,  we  should 
employ  a  feather  edge  division  of  tissue  without  the  con- 
tusion of  handling  or  sponging  so  ;i>  to  Leave  a  clean  incised 

wound  surface   only. 

By  avoiding  retraction,  by  sharp  dissection  an  I  by  thor- 
oughly blocking  the  operative  held,  an  amputation  may  be 
carried  through  withoul  :i  change  in  the  pulse-rate,  no  matter 

\\  lint    may  be  t  he  si/e  of  t  he  limb. 

203 


204  ANOCI-ASSOCIATION 

In  cases  of  acute  shock  from  crushed  limbs,  deep  morphin- 
ization  is  imperative. 

On  account  of  the  danger  of  infection  in  these  emergency 
cases,  the  use  of  quinin  and  urea  hydrochlorid  is  contra- 
indicated  unless  the  risk  be  grave,  when  a  deep  infiltration 
should  be  made  beyond  the  immediate  field  of  operation,  as 
in  such  a  case  the  choice  is  between  death  from  shock  and  de- 
layed healing. 

If  recovery  be  doubtful  in  a  case  of  acute  shock,  then  an 
immediate  transfusion  of  blood  should  be  given.  This  will 
prove  a  saving  measure  unless  the  brain-cells  have  become 
so  extensively  disrupted  by  anemia  that  their  restoration  is 
impossible. 

On  this  plan  we  have  performed  sixteen  amputations  for 

gangrene  resulting  from  diabetes  or  thrombosis,  without  a 

fatality. 

OSTEOTOMY 

In  extensive  operations  for  chronic  infections  of  the  bones 

with  necrosis  and  caries  the  risk  is  considerable,  especially 

in  children  reduced  by  long  suffering  and  by  suppuration. 

In  these  cases,  on  account  of  local  conditions,  nerve  blocking 

is  not  practicable,  but  the  surgeon  should  minimize  the  loss 

of  blood  by  the  use  of  the  tourniquet ;  and  he  should  minimize 

the  trauma  by  gentle  manipulations,  and  by  the  use  of  as  few 

movements  as  possible.    By  following  the  brilliant  technique 

of    Murphy  in    these    cases,    the    resultant   shock   will   be 

minimized. 

GENERAL  CONSIDERATIONS  IN  ACCIDENT  CASES 
The   principle    of   anoci-association   is    a    splendid  guide 
in  the  care  of    patients    who  have   sustained  fractures  or 
dislocations,  who  have  been  mangled  by  machinery  or  in 


OPERATIONS    ON    THE    EXTREMITIES — ACCIDENTS         205 

railway  accidents,  or  have  been  pierced  by  Indicts  or  knives. 
These  patients  are  suffering  not  only  from  the  actual  trauma 
and  consequent  hemorrhage,  hut  in  most  instances  from  such 
over) lowering  fear  that  by  that  fear  itself  their  bodies 
would  still  be  damaged,  even  if  there  were  no  obvious 
physical  injury. 

If  there  be  no  contraindication  to  its  use,  solacing  doses  of 
morphin  should  be  given  not  text-book  doses,  but  re- 
peated physiologic  doses  until  quiescence  is  established. 
Should  an  operation  be  required,  complete  anoci-associaiion 
is  urgently  indicated  to  protect  the  already  depleted  brain- 
cells.  If  amputation  be  necessary,  sacral  anesthesia,  spinal 
anesthesia,  or  local  nerve  blocking  should  without  fail  be 
employed  in  addition  to  nitrous-oxid-oxygen.  Should  the 
brain  be  dangerously  anemic  as  a  result  of  hemorrhage  or 
shock,  or  both,  then  a  timely  direct  transfusion  of  blood 
should  be  made.  By  the  combination  of  these  methods 
the  dangerous  phase  may  be  safely  tided  over. 

In  open,  crushed  wounds,  quinin  and  urea  hydrochlorid 
would  bean  ideal  protection  againsl  postoperative  depression 
ucic  it  not  for  the  irritating  effects  of  this  drug.      In  a  close 

risk  in  which  there  are  extensive  lacerations,  however,  "safety 
lirst  "  demands  that  the  firsl  two  critical  days  Ik-  tided  over 
by  the  aid  of  ample  infill  rat  ion  at  a  distance,  even  though  the 
Inter  wound  repair  be  delayed.  In  penetrating  wounds  the 
Burgeon  should  have  definitely  planned,  concise,  short  int. 
efficient  methods  such,  for  example,  as  have  been  formu- 
lated by  Dr.  John  Young  Brown  as  the  result  of  his  unex- 
celled experience  with  thi-  class  of  patients  in  civil  practice. 


CHAPTER  XVII 

THE  IMPORTANCE  OF  ANOCI-ASSOCIATION  TO  PATIENTS 

HANDICAPPED  BY  TOO  HIGH  OR  TOO 

LOW  BLOOD-PRESSURE 

A  good  heart  and  normal  blood-vessels  with  active  in- 
nervation and  with  the  capability  of  maintaining  an  average 
blood-pressure  give  a  patient  a  strong  defense  against  a 
surgical  operation.  With  almost  human  ingenuity,  how- 
ever, disease  processes  strike  at  the  strongest  defenses  of 
their  intended  victim,  and,  as  a  consequence,  all  too  seldom 
does  a  patient  come  to  the  surgeon  with  this  protective 
mechanism  unimpaired.  It  is  essential,  then,  that  we  under- 
stand well  the  causes  which  may  produce  menacing  devia- 
tions in  blood-pressure,  that  we  may  be  able  successfully 
to  combat  these  conditions  by  preliminary  and  coincident 
measures. 

HYPERTENSION 

Hypertension  may  be  but  a  temporary  condition  induced 
by  a  continued  and  intense  emotion — worry,  grief  or  anger; 
it  may  be  due  to  acute  or  chronic  infection,  to  exophthalmic 
goiter,  or  to  increased  intracranial  pressure,,  as  well  as  to  such 
more  immediate  causes  as  cardiovascular  disease  and  phys- 
ical changes  in  the  blood-vessel  walls.  From  this  enumera- 
tion it  is  obvious  at  once  that  while  some  of  the  causes  of 
hypertension  are  temporary  and  remediable,  others  are 
permanent  and  irremediable. 

206 


ANOCI-ASSOCIATION    IN    CASES    OF   HYPERTENSION       201 

In  considering  the  advisability  of  operation  upon  a  pa- 
tient with  hypertension,  therefore,  we  shall  find  that  while 
at  times  the  hazard  must  be  taken  at  once,  at  times  also, 
operation  may  be  delayed  until  the  hypertension  hazard 
has  been  eliminated  or,  to  some  extent  at  least,  diminished. 
If  a  patient  with  a  benign  tumor  be  in  the  throes  of  an  over- 
whelming grief,  or  if  he  be  passing  through  a  psychic  strain— 
the  result  of  intense  worry  or  anxiety — the  operation  may 
well  be  delayed  until  the  emotional  stress  has  passed.  A 
benign  tumor  in  a  patient  with  Graves'  disease  may  safely 
await  a  lobectomy  or  ligation,  and  the  after-cure  of  the  dom- 
inant trouble.  If  the  hypertension  be  due  to  a  pyogenic  in- 
fect ion,  the  operation  for  a  chronic  disease  may  be  delayed 
until  the  focus  has  been  eradicated.  Again,  operation  for 
benign  tumors  or  chronic  diseases  may  await  the  most  fav- 
orable phase  of  that  form  of  hypertension  which  can  be 
partially  controlled  by  nitroglycerin,  meat-free  diet,  rest 
and  diversion.  In  these  controllable  cases,  however,  we 
do  not  meet  the  great  problems  which  arc:  (1)  to  discover 
just  what  are  the  special  risks  when  operation  in  hyper- 
tension cases  cannol  be  postponed;  and  (2)  to  evolve  means 
by  which  these  risks  may  be  minimized  or  obviated. 

The  natural  sequela'  in  hypertension  cases  are  embolism, 

thrombosis,  renal  insufficiency,  angina,  pneumonia,  cardiac 
failure.  Why  are  these  dangers  precipitated  by  operation? 
We  know  thai  some  of  these  results  are  to  be  expected  when 

a  person  whose  hi l-pressure  iv  high  is  subjected  to  undue 

mental  or  physical  exertion;  to  sudden  shock,  either  physical 
oi-  psychic;  or  to  heavy  aervous  Btrain.  From  such  cases 
a  heavy  toll  of  life  is  levied  al  seasons  of  great  stress,  such  as 
financial  panics,  the  San  Francisco  earthquake,  etc. 


208  ANOCI-ASSOCIATION 

Since  hypertension  cases  meet  the  same  dangers  in  times 
of  physical  and  in  times  of  psychic  stress,  may  we  not  find 
that  the  underlying  causes  in  both  instances  are  identical? 
An  explanation  which  fits  all  cases  may  be  based  on  the 
principle  of  biologic  adaptation.  To  make  clear  the  argu- 
ment here  it  is  necessary  to  restate  briefly  that  emotional 
excitation  will  drive  the  whole  motor  mechanism,  even 
though  no  muscular  act  be  performed.  The  brain,  the  thy- 
roid, the  suprarenals,  the  liver,  the  muscles — all  the  parts  of 
the  body  that  contribute  to  fight  or  to  flight — are  activated. 
The  reason  is  clear.  In  our  phylogenetic  history  those 
causes  which  produced  fear  or  anger  or  any  form  of  emotional 
excitement  at  once  led  to  great  bodily  activity.  The  in- 
dividual put  his  entire  motor  mechanism  into  use  by  either 
running  away  from  danger  or  by  aggressively  fighting 
against  it.  As  the  human  race  developed  and  civilization 
advanced,  man  learned  to  control  the  outward  expression 
of  his  emotions,  but  it  is  still  impossible  for  him  to  control 
the  activities  of  the  mechanism  itself.  By  his  very  repres- 
sion he  increases  the  danger  of  too  great  activity,  for  the 
energy  which  formerly  would  have  been  expended  in  mo- 
tion, accumulates  within  the  mechanism  itself.  Right  here 
we  find  the  key  to  the  cause  of  damage  in  cases  of  hyper- 
tension, for  among  the  energizing  substances  thrown  into  the 
blood  stream  to  increase  the  power  of  motion  are  adrenalin 
and  glycogen.  As  there  is  no  muscular  action,  these  agents 
are  not  entirely  consumed,  while  the  body  is  shaken  and 
damaged  as  is  the  stationary  automobile  whose  engine  is  run- 
ning at  full  speed.  Besides  causing  needless  activation,  all 
these  energizing  substances  must  be  eliminated  and  so  an 
unusual  strain  is  put  upon  the  organs  of  elimination. 


ANOCI-ASSOCIATION    IN    CASES    OF    EYPERTENSION       209 

As  was  fully  enunciated  in  Chapters  II  and  III  this  reason- 
ing is  based,  not  only  upon  clinical  observations,  but  also  upon 
laboratory  experimentation,  by  means  of  which  i  1  I  we  have 
proved  conclusively  that  the  emotions  cause  as  great  ac- 
tivations of  the  brain  as  does  physical  injury  or  physical 
exertion,  and  (2)  we  not  only  have  confirmed  Cannon's 
observation  thai  emotion  in  cats  causes  an  increased  out- 
put of  adrenalin,  but  we  have  added  the  significant  fact 
that  if  the  nerve  supply  of  the  suprarenals  be  divided, 
there  is  no  increase  in  their  output. 

The  significance  of  these  two  conclusions  becomes  ob- 
vious  at  once  when  we  recall  the  rich  nerve  supply  of  tin- 
ductless  glands,  the  physical  evidence  of  brain  stimulation, 
and  the  definite  proof  that  the  brain  controls  the  adrenalin 
output. 

The  significance  of  the  increased  adrenalin  output  is  ob- 
vious when  we  remember  thai  adrenalin  specifically  stimu- 
lates the  blood-vessel  walls,  raises  the  blood-pressure,  and 
increases  the  outpul  of  glycogen  by  the  liver. 

And  in  turn  the  significance  of  the  increased  glycogen 
output  is  obvious  when  we  recall  the  physiologic  fad  thai 
glycogen  bears  the  same  relation  to  the  running  of  the 
human  motor  thai  gasoline  bears  to  the  running  of  an  auto- 
mobile. 

From  these  studies,  clinical  observations,  and  laboratory 
experiments,  therefore,  we  have  arrived  at  a  simple  expla- 
nation of  the  disastrous  effects  of  emotional  stimulation 
upon  a  patient  with  hypertension.  We  see  thai  the  emo- 
tional factor  assumes  an  increasingly  important  r61e  in  the 
performance  ol  surgical  operations.  The  elimination  ol  the 
emotional  factor  important  always  is  essential  to  the suc- 
11 


210  ANOCI-ASSOCIATION 

cessful  outcome  of  operations  upon  these  cases  whose  margin 
of  safety  is  narrow  at  the  best. 

In  addition  to  the  psychic  and  traumatic  factors,  one  other 
operative  factor  has  a  most  important  bearing  upon  our 
thesis,  and  that  is  the  anesthetic.  Ether,  however  skillfully 
it  may  be  administered,  induces  a  stage  of  psychic  stress  in 
the  earlier  stages  of  its  administration.  As  we  have  stated 
previously,  ether  immediately  impairs  the  immunity  of  the 
patient ;  it  increases  the  coagulation  time  of  the  blood ;  as  a 
fat  solvent  it  dissolves  many  of  the  body  lipoids — in  the 
brain,  the  renal  epithelium,  the  liver,  etc. — and,  as  a  conse- 
quence, there  is  an  increased  amount  of  waste  products  to 
be  eliminated  and  a  resultant  increased  tax  upon  the  organs 
of  elimination.  The  strain  of  ether  nausea  and  vomiting, 
always  a  dangerous  factor,  is  especially  so  in  cases  of  hyper- 
tension. Therefore,  the  mere  administration  of  ether  in 
these  cases  is  a  distinct  risk  per  se,  because  it  injures  and 
taxes  the  kidneys,  predisposes  to  embolism  and  pneumonia, 
and  increases  the  traumatic  and  psychic  dangers. 

We  see  then  that  hypertension  increases  the  gravity  of 
the  prognosis  in  operative  cases  unless  in  some  way  these 
adverse  factors  can  be  controlled. 

HYPOTENSION 

It  may  at  first  seem  unwarranted  to  state  that  we  can  often 
give  a  more  favorable  prognosis  in  the  case  of  a  patient  with 
hypotension  than  in  one  with  hypertension.  That  we  can 
do  so  is  due  to  the  fact  that  for  hypotension  we  have  a  defi- 
nite and  efficient  remedy.  As  the  principal  causes  of  hypo- 
tension are  hemorrhage  and  anemia,  the  condition  is  logically 
to  be  met  by  the  direct  transfusion  of  blood,  which,  as  oc- 


ANOCI-ASSOCIATION    IN    CASES    OF    HYPOTENSION        211 

casion  demands,  may  be  done  several  days  before,  just  be- 
fore or  during  the  operation,  or  immediately  thereafter. 

It  may  be  argued  thai  this  remedy,  even  though  efficient. 
is  too  difficult  to  be  practised  generally.  It  is  true  that  the 
technique  is  difficult  and  that  special  instrument-  and  -pecial 
training  are  required,  but  this  objection  is  ethical  rather 
than  scientific,  and  the  only  answer  can  be  the  ethical  (mo- 
tion:— Is  the  saving  of  human  life  worth  the  pains  of  the 
surgeon  to  train  himself  in  the  technique  of  any  procedure 
which  will  subserve  that  supreme  end? 

In  a  case  of  pathologic  hypotension  the  margin  of  safety 
is  much  reduced  and  the  prognosis  is  grave;  for  in  such  cases 
the  brain-cells  are  deteriorated  or  destroyed,  and  conse- 
quently the  vitality  is  low  and  complication-  air  facilitated. 
In  both  hypotension  and  hypertension,  therefore,  the  op- 
eration should  be  performed  under  nitrous-oxid-oxygen 
anesthesia  and  with  complete  anoci^associationf  so  that  every 
damaging  factor,  whether  psychic  or  traumatic,  may  be  ex- 
cluded and  the  narrow  margin  of  safety  may  be  preserved. 


CHAPTER  XVIII 

THE  RELATION  OF  ANOCI-ASSOCIATION  TO  POSTOPER- 
ATIVE MORBIDITY  AND  MORTALITY 

Gas  Pain.  Painful  Scar.  Nervousness.  Aseptic  Wound  Fever  and  Post- 
operative Hyperthyroidism.  Nausea  and  Vomiting — Digestive  Disturbances. 
Backache.     Infection.     Nephritis.     Pneumonia.     Mortality. 

The  best  clue  to  the  comparative  value  of  different  oper- 
ative methods  is  found  in  a  study  of  the  postoperative  mor- 
bidity. 

After  operations  performed  under  ether  anesthesia  alone, 
surgeons  are  confronted  constantly  with  a  familiar  train  of 
disastrous  sequelae,  painful  to  the  patient  and  discouraging 
to  the  physician.  The  immediate  sequelae  include  gas  pain, 
nausea,  and  aseptic  wound  fever  while  the  later  results 
range  all  the  way  from  painful  scar  alone  to  the  long  train 
of  symptoms  accompanying  "  postoperative  neurasthenia." 

Here  again  biologic  considerations  teach  us  the  cause  of 
each  of  these  disturbances  and  show  how  and  why  they  may 
be  obviated  by  the  strategical  maneuvers  of  anoci-associa- 
tion. 

It  has  already  been  stated  that  a  study  of  the  pulse  dur- 
ing and  after  the  operation  perhaps  gives  us  our  best  clue 
to  the  value  of  the  protective  technique  of  anoci-association 
and  explains  the  strikingly  decreased  postoperative  mor- 
bidity after  anoci  operations.  A  comparison  of  500  consec- 
utive cases  operated  upon  under  ether  with  500  consecutive 
cases  operated  upon  under  anoci-association  showed  in  the 

212 


POST-OPERATIVE    .MORBIDITY    AND    MORTALITY 


213 


ether  cases  an  increase  of  21.6  beats  during  operation,  while 
the  anoci  cases  showed  a  fall  of  .83  during  the  operation. 


Be^t  e. 

80 

90 

100 

110 

Ether. 

jfooo  ca.sej] 

Sef  ote 

After. 

NaO. 

[iooo  cases] 

Before 

Af^er.J 

Anoci. 

"Before. 

[Soz  cxses] 

After. 

The  horizontal  lines  represent  the  averages  derived  from  101)0  cases  operated 
upon  under  ether,  1000  under  nitrous-oxid-oxygen,  and  502  under  complete 
anoci-a880ciation. 

Flo.   52. — Till:    PtTLSE-RATE    [MMEDIATELY    BEFORE   AM)    1 MMKDIATKLV    A  I  PES 

I  ►PERATION. 


Seats. 

10 

80 

90 

100 

110 

no 

Ether. 

NiO, 

Anoci. 

Bach  bravy  line  represents  the  average  ■"■  i  ite  "i  ten  oonsecutive  miscellaneous 

during  the  f  i  r — t  four  da]  9  after  operation. 

In.  •">:;  Comparative  Clinical  Results  oi  Consecutivi  Operations 
Performed  under  Ether,  under  Nitrous-oxid-oxygen,  \m>  under 
<  Iompli  1 1     1  not   -■■      ■  iaiion. 


GAS  PAIN 

Postoperal  ive  gas  pain  con  be  explained  as  a  biologic  adap- 


214  ANOCI-ASSOCIATION 

tation  to  overcome  infection.  In  the  course  of  evolution, 
all  abdominal  penetrations  were  infected,  and,  therefore,  as  a 
natural  sequence,  a  protective  mechanism  within  the  abdomen 
was  evolved  as  a  means  of  protection.  Most  infections  may 
be  overcome  if  they  can  be  localized.  To  accomplish  such 
a  localization  of  an  infection  in  the  abdomen,  the  intestines 
and  the  abdominal  wall  must  be  kept  fixed  against  each  other. 
To  this  end  the  intestine  must  be  distended  with  gas,  the  ab- 
dominal wall  must  be  rigid.  If  the  intestine  be  distended 
with  gas  and  fixed,  then  digestion  must  cease.  If  digestion 
be  arrested,  then  there  is  anorexia,  or  even  vomiting  to  expel 
food  from  the  stomach.  These  facts  show  us  how  postop- 
erative gas  pains  are  due  to  a  biologic  adaptation  to  over- 
come infection,  and  explain  their  resemblance  to  incipient 
peritonitis.  Nature  does  not  depend  upon  the  surgeon,  or 
perhaps  she  knows  the  surgeon  too  well.  The  test  of  this 
hypothesis  is  easily  made.  If  the  brain  through  which  this 
adaptive  response  is  made  be  kept  in  ignorance  of  the  in- 
cision into  the  peritoneum  (a)  by  progressive  novocain 
blocking  throughout  the  operation,  and  (b)  by  postoper- 
ative quinin  and  urea  blocking  to  break  later  communica- 
tion with  the  brain  through  stitch  tension,  then  there  should 
be  no  gas  pains.  Clinical  experience  has  abundantly  con- 
firmed this  hypothesis.  It  must  be  remembered  that  if  a 
single  nerve  filament  escape  the  block,  there  will  be  gas 
pains. 

PAINFUL  SCAR 
The  lesion  which  produces  a  painful  scar  is  in  the  brain, 
not  at  the  site  of  the  wound.     It  is  explained  by  a  funda- 
mental principle  of  nerve  conduction;   that  is,  that  a  strong 
traumatic   or  psychic   stimulus   produces   some   change   in 


POST-OPERATIVE    MORBIDITY    AXD    MORTALITY  215 

conductivity  somewhere  in  its  cerebral  arc,  the  effect  of 
which  is  to  lower  the  threshold  of  that  arc. 

The  following  clinical  case  well  illustrates  this  point: 
A  physician,  when  about  to  leave  his  office  one  evening, 
was  confronted  by  a  man  who  pointed  a  pistol  at  him 
and  ordered  him  to  throw  up  his  hands.  The  assailant 
was  >o  nervous  that  the  hand  holding  the  pistol  trembled 
constantly,  thereby  increasing  the  fear  of  the  threatened 
physician  who  was  in  terror  lest  the  nervousness  of  the  man 
should  cause  an  accidental  discharge  of  the  pistol.  The 
burglar  made  the  doctor  turn  round,  pushed  him  face  against 
the  wall  and  pressed  the  pistol  close  between  his  shoulder-, 
this  position  being  maintained  while  with  his  free  hand  the 
burglar  ransacked  desk  and  pockets.  The  physician  stated 
that  for  weeks,  even  months,  after  this  occurrence  he  felt 
in  his  back  the  actual  sensation  of  the  pressure  from  the 
pistol,  as  real  a  sensation  as  if  the  pistol  were  actually  there. 
A  year  alter  the  event,  even,  the  impression  could  be  vividly 
recalled. 

After  the  stimulus  of  physical  trauma,  the  result  is  sim- 
ilar. The  arc  receiving  the  stimulus  suffers  a  lowered  thresh- 
old and  hence  from  that  time  on  mere  trifles  become  ade- 
quate stimuli.  Mosl  familiar  examples  of  this  result  are 
the  sensitiveness  of  limbs  alter  fractures  and  the  painful 
Btumps  of  crushed  limbs.  Now  if  an  operation  be  so  per- 
formed thai  no  strong  stimulus  reaches  the  brain,  either  dur- 
ing or  niter  the  operation,  then  the  threshold  of  the  cere- 
bral   are    from    the    WOUnd    will    not    be    lowered.      Since    the 

threshold  is  not  lowered,  contact  with  the  -car  or  any  In- 
jury to  that  part  will  have  little  more  effect  than  will  con- 
tact   With    all}'   other   part    of   the    body.        llclice   we     nv    how 


216  ANOCI-ASSOCIATION 

painful  scars  may  be  minimized  or  prevented  by  complete 
anoci-association.  Our  clinical  data  seem  to  support  this 
hypothesis,  although  these  have  not  as  yet  been  fully  worked 
out. 

NERVOUSNESS 

The  explanation  of  "painful  scar"  applies  also  to  post- 
operative "nervousness."  When  in  the  night  one  is 
threatened  with  an  unknown  danger  the  brain  threshold 
is  always  lowered,  apparently  as  an  adaptation  to  the  more 
swift  and  accurate  detection  of  danger.  As  stated  above, 
when  one  has  received  a  crushing  physical  injury,  there  is  a 
universal  lowering  of  the  threshold.  During  these  states  of 
tenseness  minor  stimuli  have  major  effects,  or,  in  other 
words,  one  is  "nervous." 

The  subconscious  brain  being  tortured  directly  during 
unblocked  operations  under  inhalation  anesthesia,  the  re- 
sultant general  effect  on  the  brain  thresholds  is  demon- 
strably the  same  as  if  the  injury  had  been  inflicted  without 
anesthesia, — that  is,  after  the  ordeal  of  punishment  of  the 
subconscious  mind  during  an  operation  the  patient  emerges 
"nervous,"  "exhausted";  and,  since  a  low  threshold  is 
lavish  in  its  waste  of  nervous  energy,  recuperation  is  slow. 
Hence  there  results  a  period  of  postoperative  nervousness, 
of  postoperative  loss  of  efficiency.  It  is  obvious — and 
clinical  experience  abundantly  proves — that  the  brain  thresh- 
old is  preserved  by  complete  anoci-association,  hence  the 
unpleasant  damaging  postoperative  phenomena  are  min- 
imized. 


POST-OPERATIVE    .MORBIDITY    AND    MORTALITY  217 

ASEPTIC    WOUND    FEVER    AND    POSTOPERATIVE 
HYPERTHYROIDISM 

Since  it  is  a  physical  law  that  any  form  of  force  may  be 
converted  into  heat,  and  that  heat  thus  produced,  if  not  at 
once  transformed  into  motion,  must  increase  the  temper- 
ature of  the  body  affected,  we  see  readily  why  any  stimulus, 
mechanical  or  physical,  which  normally  would  cause  in- 
creased motor  activity,  must  cause  a  rise  in  temperature  if 
complete  motor  expression  is  impossible.  Anything,  there- 
fore, that  drives  the  motor  mechanism  of  the  body  beyond 
the  point  of  normal  expression  will  cause  fever.  Anger, 
athletic  contests,  fear,  physical  injuries,  all  produce  a  rapid 
oxidation  of  certain  body  compounds  too  great  for  complete 
translation  into  motion. 

In  operations  under  general  anesthesia  only,  we  expected 
routinely  to  see  some  postoperative  rise  of  temperature  as  a 
resull  of  the  suppressed  power  of  motor  response  to  the 
physical  and  psychical  injury;  but  by  the  use  of  (inoci-asso- 
ciation,  both  during  and  after  the  operation,  we  discovered 
a  change  of  postoperative  temperature  and  pulse-rate.  We 
were,  therefore,  forced  to  the  conclusion  that,  barring  in- 
fection and  the  absorption  of  hemoglobin,  postoperative 
fever  is  the  resull  of  increased  oxidation,  this  being  in  turn 
the  result  of  the  psychic  and  traumatic  stimuli  of  the  opera- 
tion to  which  natural  response  has  been  denied. 

These  observations  led  us  to  a  further  knowledge  of  the 
phenomena   accompanying  Graves'   disease.     This  disease 

being  due  to  ;i  disarrangement  ol  the  general  motor  mechan- 
ism   whereby  the   threshold   of   the   brain    to   both    psychical 

and  traumatic  stimuli  has  been  lowered  in  varying  degree, 

tin'  stimulus  which  in  the  normal  individual  would  cause  no 


218  ANOCI-ASSOCIATION 

appreciable  change  in  pulse  or  temperature,  will,  in  a  case 
of  Graves'  disease,  drive  the  brain  and  body  so  fast  that 
greatly  increased  motor  activity  and  a  rise  in  temperature 
are  caused.  Anything,  therefore,  that  raises  the  threshold 
of  the  brain  to  stimuli  must  diminish  the  susceptibility 
to  pulse  and  temperature  changes  in  the  patient  suffering 
from  Graves'  disease  as  well  as  in  the  normal  individual. 
This  explains  why  patients  under  morphin  or  in  a  stupor 
show  little  change  after  excitation,  and  why  an  operation 
performed  under  anoci-association  is  followed  by  diminished 
or  no  aseptic  fever  and  in  Graves'  disease  by  greatly  dimin- 
ished or  no  so-called  "hyperthyroidism." 

NAUSEA  AND  VOMITING— DIGESTIVE  DISTURBANCES 

The  intensity  of  these  postoperative  symptoms  depends 
upon  the  location  of  the  operation;  on  the  kind  of  general 
anesthetic  which  is  used;  on  the  amount  of  postoperative 
pain;  and  on  the  gentleness  or  roughness  of  the  operator. 
Appetite  may  be  driven  away  and  digestion  may  be  broken 
down  by  even  a  simple  operation  on  any  part  of  the  body  if 
it  be  crudely  and  roughly  performed  under  nauseating  ether 
anesthesia,  or  if  the  tension  of  the  stitches  be  too  great  and 
the  dressings  too  tightly  applied. 

On  the  other  hand,  nausea  and  vomiting  may  be  obviated 
and  the  digestive  impairment  will  be  minimized  by  the  em- 
ployment of  nitrous-oxid-oxygen  anesthesia,  sharp  knife 
dissection,  the  gentle  manipulation  of  tissues,  cautious  des- 
patch in  operating,  complete  nerve  blocking  during  the  op- 
eration, and  for  several  days  thereafter ;  the  careful  insertion 
of  stitches  and  application  of  bandages.  No  matter  how 
extensive  or  what  the  location  of  the  operation,  if  it  be  per- 


POST-OPERATIVE    MORBIDITY    AND    MORTALITY  219 

formed  under  complete  anoci-association,  a  nursing  mother 

will  be  able  to  give  each  regular  feeding,  and  the  babe  will 

give  no  token  of  digestive  disturbance.     There  may  be  mor- 

phin  nausea,  however,  to  the  degree  ordinarily  caused  by 

that  drug. 

BACKACHE 

In  anociated  operations  the  patient  rests  on  the  operating 
table  on  a  water-bed.  For  this  reason,  and  since  the  muscles 
are  not  relaxed  under  the  mild  nitrous-oxid-oxygen  anes- 
thesia, heavy  strain  on  the  ligaments  and  joints  is  elimin- 
ated, and  backache  is  averted,  excepting  that  backache 
which  is  produced  by  the  technique  of  certain  abdominal 
operations,  such  as  supravaginal  hysterectomy.  This  ton 
may  be  avoided  by  the  complete  infiltration  of  the  stumps 
witli  the  nerve-blocking  anesthetic.  In  our  comparative 
study  we  found  that  in  the  postoperative  bedside  notes  of 
500  cases  operated  upon  under  ether  anesthesia,  backache 
i-  mentioned  in  91  cases,  while  in  500  cases  under  anoci- 
association  it  is  mentioned  but  30  times. 

INFECTION 

As  we  have  stated  in  Chapter  IX.  ether  anesthetizes  the 
phagocytes  as  well  as  the  man,  and  so  places  the  patienl  in 

tin'  position  <>!'  a  citadel  when,  at   the  hour  of  assaull   by  t  he 

enemy,  the  defenders  are  asleep  in  the  trenches.  It  nitrous- 
oxid-oxygen  be  used,  however,  the  phagocytes  remain  ready 
for  action  and  the  danger  of  infection  is  therefore  Lessened. 

NEPHRITIS 

The  lipoid-solvenl  action  of  ether  is  sufficient  reason  for 
the  ether  nephritis,  as  the  renal  epithelium  contain-  much 
lipoid  substance.     Moreover,  other  products  of  ether  solu- 


220  ANOCI-ASSOCIATION 

tion  in  various  parts  of  the  body  are  thrown  on  the  kidneys 
for  elimination.  The  use  of  nitrous-oxid-oxygen  relieves 
the  kidneys  from  this  strain  and  the  danger  of  nephritis 
from  this  cause  is  eliminated. 

PNEUMONIA 

Many  theories  have  been  advanced  to  account  for  the 
more  frequent  occurrence  of  pneumonia  after  operations  in 
the  upper  abdomen  than  after  operations  in  the  lower  ab- 
domen, on  the  back,  or  on  the  extremities.  That  pneu- 
monia is  not  due  to  ether  alone  is  proved  by  its  occurrence 
after  operations  under  local  anesthesia;  that  it  is  not  due  to 
infection  alone  is  shown  by  the  fact  that  it  occurs  as  fre- 
quently in  connection  with  uninfected  as  with  infected 
wounds;  that  it  is  not  due  to  emboli  or  thrombosis  alone  is 
evident  since  superficial  wounds  are  rarely  followed  by  pneu- 
monia. 

The  clue  to  the  real  cause  was  found  in  a  comparison  of 
the  postoperative  behavior  of  patients  operated  upon  under 
the  old  nocuous  technique  with  that  of  patients  operated 
upon  under  anoci-association.  After  the  nocuous  operation 
the  wound  is  tender.  Now  the  upper  abdominal  muscles 
have  especially  important  respiratory  functions.  In  each 
respiratory  movement  these  powerful  muscles  pull  on  the 
stitches  which  hold  together  the  divided  wall.  The  exquisite 
pain  produced  by  this  respiratory  pull  causes  an  inhibition  of 
the  muscular  contraction  on  the  side  of  the  incision,  or  on 
both  sides  of  the  incision  if  it  be  median.  As  a  result,  the  ex- 
cursion of  the  lower  chest  wall  is  diminished  so  that  the  lower 
lobes  of  the  lungs  cannot  be  filled  completely.  That  a  les- 
sened exchange  of  air  in  the  lower  lobes  predisposes  to  pneu- 


POST-OPERATIVE    MORBIDITY    AND    MORTALITY 


221 


monia  is  proved  by  noting  the  predisposition  to  pneumonia 
in  cases  of  localized  pleurisy,  in  which  the  pain  causes  an 
inhibition  of  free  excursion  in  the  part  of  the  chest  which  is 
involved.  The  resultant  pneumonia  occurs  in  that  portion 
of  the  lung  whose  free  action  is  inhibited.  After  gall-bladder 
operations  pneumonia  begins  not  in  the  left  but  in  the  right 
lobe,  whereas,  were  the  pneumonia  embolic  in  its  origin,  the 
lobes  would  fare  alike. 

The  diminution  of  the  number  of  cases  of  postoperative 
pneumonia  since  the  adoption  of  the  technique  of  anoci-asso- 
ciation  is  the  final  proof  of  this  reasoning  as  to  its  cause. 
Because  of  the  lack  of  local  tenderness  in  the  field  of  opera- 
tion produced  by  the  technique  of  the  operation  itself  and 
by  the  postoperative  nerve  blocking,  there  is  diminished  or 
no  inhibition  of  the  respiratory  excursions.     This  also  with- 


MOPTA^ITV     r 

rati; 
1908 
1912 
1913 


Fio.  54.  Comparison  oi  the  Mortality  Rate  oi  III  Operations  Per- 
formed at  Lakeside  Hospital  hi  the  \i  raoRS  \\i>  cheis  Resident 
Staff  during  1908  im.  Yeah  before  Anod-associatum  was  In- 
troduced wiiii  the  Mortality  Rati  oi  che  Last  Two  Vi  uis,  L912 
AM.  1913. 

out  doubt  explains  the  reduced  mortality  of  operations  for 
umbilical  hernia  performed  with  the  transverse  incision 
(Mayo  . 

The  clinical  observations  here  reported  have  been  con- 
firmed by  the  personal  experiences  of  Bloodgood,  Cabot, 
Codman,  and  a  number  of  other  American  surgeon  ;  bj 
Moynihan  and  others  in  England. 


222  ANOCI-ASSOCIATION 

MORTALITY 

Not  only  the  lessened  postoperative  morbidity,  but  a  re- 
duced mortality  rate  also  bears  witness  to  the  value  of  the 
technique  by  means  of  which  anoci-association  is  attained. 
A  study  of  the  statistics  of  the  Lakeside  Hospital  shows  that 
in  1908,  the  year  before  the  adoption  of  the  principle  of 
anoci-association,  the  mortality  rate  of  all  operations  per- 
formed by  the  authors  and  their  resident  staff  was  4.4  per 
cent.;  in  1912  the  mortality  rate  had  fallen  to  1.9  per  cent.; 
and  last  year,  1913,  to  1.8.     (See  Fig.  54.) 


CHAPTER  XIX 
SUMMARY 

The  development  of  the  principle  of  anod-assodation  and 
the  application  of  that  principle  to  the  operations  described 
in  this  monograph  are  the  result  of  prolonged  laboratory 
experimentation;  of  a  critical  comparative  study  of  the  clini- 
cal data  of  operations  performed  at  the  Lakeside  Hospital 
under  ether  alone,  under  nitrous-oxid-oxygen  alone,  and 
under  complete  anoci-association;  and  of  the  practical 
experience  gained  by  the  authors  in  the  treatment  of  over 
26,000  surgical  cases. 

In  this  monograph  we  have  endeavored  to  show  that 
shock  may  be  produced  by  physical  trauma  with  or  without 
inhalation  anesthesia;  that  in  the  distribution  of  the  de- 
fending nociceptors  we  have  a  brief  epitome  of  our  phylo- 
genetic  struggle  for  existence,  as  a  result  of  which  those 
parts  of  the  body  having  the  greatesl  number  of  nociceptors 
and  those  which  defend  the  mosl  importanl  regions  by  mus- 
cular action  are  the  most  shock-producing  on  receiving 
trauma.  We  have  shown  thai  nitrous-oxid-oxygen  anesthesia 
as  compared  to  ether  anesthesia  is  a  protective  agent  againsl 
shock  protective  through  its  interference  with  the  use  of 
oxygen  by  the  brain-cells.  We  have  shown  thai  the  physi- 
cal exhaustion  is  the  resull  of  demonstrable  changes  in  certain 
kinetic  organs  notably  the  brain,  the  suprarenals,  and  the 
liver,  and  thai  these  changes  are  due  to  an  adaptive  response 
of  the  organism  to  the  injury  a  silent,  motionless  eflfoii  to 
escape  from  the  physical  injury  of  tl Deration,  and  thai 


224  ANOCI-ASSOCIATION 

therefore  if  the  field  of  operation  be  blocked  by  local  anes- 
thesia, or  if  the  nerve  connection  between  the  brain  and  the 
injury  be  blocked,  physical  injury  alone  can  cause  no  shock. 
We  have  shown  that  the  motor  mechanism  may  be  power- 
fully driven  by  psychic  stimuli — perhaps  as  powerfully  as 
by  traumatism  and  physical  exhaustion — and  that  cor- 
responding changes  are  produced  in  the  organs  of  the  kinetic 
system.  We  have  seen  that  when  both  the  traumatic  and 
the  psychic  stimuli  are  excluded  shock  cannot  be  produced. 
We  have  found  that  the  essential  pathology  of  shock  is 
identical  whatever  its  cause.  That  is,  when  the  kinetic 
system  is  driven  at  an  overwhelming  rate  of  speed — as  by 
severe  physical  injury;  by  intense  emotional  excitation; 
by  perforation  of  the  intestines;  by  the  sudden  onset  of  an 
infectious  disease ;  by  an  overdose  of  strychnia;  by  a  Mara- 
thon race;  by  foreign  proteids;  by  anaph}daxis — the  result 
of  these  overwhelming  activations  of  the  kinetic  system  is 
a  condition  which  is  identical  however  it  may  be  clinically 
designated,  whether  as  surgical  or  traumatic  shock,  toxic 
shock,  anaphylactic  shock,  drug  shock,  etc. 

As  a  result  of  the  acceptance  of  this  theory  an  operative 
method  has  been  evolved  by  means  of  which  shock  is  min- 
imized or  eliminated  according  as  the  principle  of  anoci- 
association  is  partially  or  completely  applied. 

The  practical  value  of  anoci-association  is  attested  by  the 
fact  that  in  the  authors'  clinic  both  the  mortality  rate  and 
the  postoperative  morbidity  have  been  reduced  by  the  appli- 
cation of  this  principle. 

Were  it  possible  to  add  to  the  surgeon's  experience  an  ex- 
pression of  the  subjective  symptoms  of  the  patient,  the 
proof  of  the  value  of  anoci-association  would  be  even  more 


SUMMARY  225 

striking.  There  is  no  longer  any  need  of  the  postoperative 
recovery  room;  the  work  of  the  nurses  is  lessened;  and  the 
clinical  aspect,  both  in  and  out  of  the  operating  room,  is 
altered. 

To  achieve  these  results  means  a  thorough  understand- 
ing of  the  principle  on  which  the  technique  is  founded; 
it  necessitates  the  intelligent  and  special  training  of  assist- 
ants, interns,  anesthetists,  hospital  officials,  and  nurses; 
it  means  a  careful  hand  and  a  sharp  scalpel;  it  presupposes  a 
mind  free  from  dogma  and  tradition;  it  means  that  no  detail 
is  too  petty  for  the  careful  attention  of  the  surgeon  himself. 
Above  all  it  means  that  from  the  patient's  first  appearance 
in  the  surgeon's  consulting  room  throughout  the  entire 
cycle  of  hospital  entrance,  operation,  and  exit  from  the  hos- 
pital there  must  be  no  sharp  points  of  contact,  either  psychic 
or  physical. 

It'  performed  perfunctorily,  as  a  dull  ritual,  the  technique 
oi anod-a88odation  will  fail;  it  can  accomplish  its  purpose 
only  when  each  detail,  however  minute,  is  considered  from  the 
viewpoint  of  the  individual  patient. 


i.-, 


APPENDIX 

THE  TECHNIQUE  OF  ADMINISTERING  NITROUS-OXID- 
OXYGEN  ANESTHESIA 

BY  AGATHA  HODGINS 

Chief  Anesthetist,   Lakeside  Hospital 

PRELIMINARY 

The  apparatus  must  be  one  that  will  give  constantly  an 
even  mixture  of  nitrous  oxid  and  oxygen  in  whatever  propor- 
tions are  required,  and  it  should  also  provide  means  for 
adding  ether-vapor  in  any  required  amount  to  the  nitrous- 
oxid-oxygen  mixture.  This  important  point  will  be  re- 
ferred to  later. 

Our  patients  usually  come  to  the  operating  room  in  a  calm 
and  comfortable  frame  of  mind.  This  tranquillity  is  partly 
due  to  the  preliminary  hypodermic  medication,  but  even 
more  to  the  special  management  of  the  patient.  The 
usual  preoperative  hypodermic  medication  is  ^  gr.  morphin 
and  -j-J-q-  gr.  scopolamin.  In  alcoholics  or  for  particularly 
large  muscular  men  this  dose  may  be  increased  to  l/i  gr. 
morphin  and  T^u  gr.  scopolamin.  This  is  the  maximum 
dose,  however,  and  is  seldom  used.  '  Frequently  less  than 
the  usual  dose  is  given,  while  to  children  under  ten  years 
of  age,  to  the  aged,  and  to  patients  enfeebled  from  any 
cause  no  preliminary  medication  is  given. 

The  reassuring  attitude  of  the  surgeons  and  nurses  be- 
fore the  operation  is  a  factor  which  contributes  greatly  to 
the  mental  comfort  of  the  patient  and  to  the  efficiency  of  the 

226 


ADMINISTERING    NITROUS-OXID-ON  Y<  IKN    ANESTHESIA   22, 

anesthetic.  It  is  our  rule  thai  the  operating  room  be  kept 
absolutely  quiet — no  talking,  rattling  of  instrument-  or 
other  noise  is  allowed,  and  no  ostentatious  preparation  is 
seen.  The  patient  is  never  touched  or  restrained  until  he  is 
quite  asleep. 

INDUCTION  OF  ANESTHESIA— FIRST  STAGE 

The  pulse,  respiration,  color  and  physical  characteristics 
of  the  patient  are  first  noted.  The  induction  of  anesthesia 
is  gradual,  slow  and  comfortably  reassuring.  The  mask  is 
qoI  finally  adjusted  until  the  patient  is  oblivious  of  his  sur- 
roundings. 

The  total  exclusion  of  air  and  an  adequate  mechanical 
adjustmenl  of  the  neck  and  jaw  are  necessary.  The  posi- 
tion of  the  head  should  be  comfortable, — neither  flexed  nor 
extended.  Attention  to  these  points  will  assure  free  res- 
piratory exchange  and  will  overcome  the  tendency  of  the 
tongue  tu  drop  back. 

Beginners  are  taught  to  work  with  the  patient'-  head  on 
it-  side  a-  ;i  safeguard  in  case  of  vomiting,  for  a-  the  limits 
of  nitrous-oxid-oxygen  anesthesia  are  narrow  it  requires  ex- 
perience to  enable  one  to  recognize  the  warning  before 
nausea  occurs.  Nausea  may  resull  from  too  much  nitrous 
oxid  as  well  as  from  an  uneven  light  anesthesia.  It  is  im- 
portant, therefore,  to  establish  anesthesia  satisfactorily  by 
:i  careful  and  gradual  administration  before  the  operation  is 
commenced.  The  proper  mixture  of  gas  and  oxygen  musl 
be  empirically  ascertained  for  each  patient. 

The  average  patienl   take-  nitrous-oxid-oxygen  without 

trouble,  but  the  anotlietbt  should  never  assume  tliat 
t  rouble  mav   li"l    I  M-elir. 


228  ANOCI-ASSOCIATION 

In  the  management  of  a  difficult  case,  good  judgment, 
careful  adjustment  of  the  anesthetic,  and  time  are  the  im- 
portant factors.  An  anesthetist  should  never  feel  hurried. 
The  gradual  induction  and  even  adjustment  of  the  anesthetic 
prevent  the  jactitation  and  clonic  spasm  which  were  for- 
merly associated  with  nitrous-oxid  anesthesia. 

The  mental  control  of  the  patient  is  of  the  greatest  im- 
portance. No  mention  should  be  made  of  fear  or  hurt,  but 
it  should  be  impressed  upon  the  patient  that  he  will  be  well 
cared  for  and  that  the  operation  will  soon  be  over.  The  an- 
esthetist should  watch  the  patient's  eyes  that  he  may  know 
when  to  tell  him  to  "let  go." 

Patients  most  commonly  fear  that  the  operation  may  be 
started  before  they  are  asleep,  this  being  especially  true  of 
women  of  a  certain  nervous  type  and  of  foreigners.  For- 
eigners especially  are  apt  to  fear  that  they  will  never  wake 
up.  Reassurance  on  this  point  is  always  a  comfort  to  them. 
We  try  to  divert  the  minds  of  little  children  from  their  sur- 
roundings, and  to  make  them  feel  that  the  operation  is  the 
first  step  toward  getting  well  and  going  home.  Personally 
I  prefer  to  have  the  child  entirely  under  my  own  manage- 
ment, for  a  child  quickly  notices  the  anxiety  which  is  al- 
most invariably  betrayed  by  the  expression  of  the  parents, 
however  sensible  they  may  be.  From  the  anesthetist's 
point  of  view  a  temporary  " Peter  Pan"  type  of  child  is 
desirable. 

INDUCTION  OF  ANESTHESIA— SECOND  STAGE 

The  second  stage  of  anesthesia  is  the  most  difficult  to 
manage.  As  the  patient  is  now  unconscious,  he  can  no 
longer  be  controlled  by  suggestion,  and  the  anesthetist  must 


ADMINISTERING    NITROUS-OXID-OXYGEN    ANESTHESIA  229 

depend  entirely  upon  his  management  of  the  anesthetic  for 
the  control  of  the  further  psychical  and  physiological  phe- 
nomena. In  some  cases  unpleasant  dreams  or  sensations 
occur  which  cause  increased  resistance  to  the  anesthetic. 

The  most  difficult  patients  to  deal  with  in  this  stage  are 
heavily  built  muscular  men.  Patients  of  the  resistant 
neurotic  type,  those  under  deep  fear  of  the  anesthetic,  and 
alcoholics  form  a  separate  class.  These  patients  often  show 
muscular  rigidity  and  difficult  respiration  which  prevent  the 
much-desired  even  anesthesia,  and,  as  a  consequence  of  the 
uneven  anesthesia,  nausea  is  produced.  With  alcoholics 
the  addition  of  ether-vapor  is  usually  necessary  to  secure  good 
anesthesia  without  cyanosis.  Ether-vapor  should  be  added 
gradually  so  that  coughing  and  spasm  of  the  respiratory 
muscles  may  be  avoided.  In  these  difficult  cases,  nitrous- 
oxid-oxygen  anesthesia  is  more  easily  induced  than  is  straight 
ether  anesthesia.  Rigidity  and  resistance  in  the  plethoric 
and  the  alcoholic  must  be  overcome  early,  as- otherwise  even 
anesl  hesia  cannot  be  maintained. 

With  the  neurotic  resistant  patient  time  and  a  gradual 
adjustment  of  the  anesthetic  mixture  are  essential.  In  these 
cases  it  is  often  difficult  to  secure  a  tranquil  anesthesia,  but 
this  musl  be  attained  before  the  operation  is  begun.  After 
the  patienl  is  tranquilly  asleep,  the  initial  trauma,  however 
slight  the  first  prick  of  the  novocain  needle  even  will 
give  the  due  to  the  further  mixture  of  the  anesthetic. 

In  anemic,  cachectic  and  feeble  patients,  the  proper 
amounl  of  oxygen  i-  most  important.  These  frail  patients 
do  not  tolerate  even  slight  asphyxia.  After  an  even  induc- 
tion of  the  anesthetic  it  is  best  to  give  ;i  mixture  containing 
:i  higher  percentage  of  oxygen. 


230  ANOCI-ASSOCIATION 

In  cases  of  acute  intestinal  obstruction  the  head  should  be 
kept  well  on  the  side,  that  in  case  vomiting  occur  the  anes- 
thetist may  be  prepared  to  prevent  the  vomitus  from  being 
inhaled.  Since  vomiting  may  come  on  quickly  without 
perceptible  warning  the  anesthetist  must  be  strictly  on  guard. 
This  rule  applies  to  any  case  with  a  history  of  preoperative 
vomiting,  especially  if  for  any  reason  it  demands  a  light  an- 
esthetic. Any  case  which  has  not  received  preparation  for 
operation  must  also  be  closely  guarded  against  vomiting. 

As  compared  with  ether  anesthesia,  however,  the  patient 
under  nitrous-oxid-oxygen  is  much  less  likely  to  inhale  the 
vomitus,  as,  the  anesthesia  being  lighter,  there  is  less  re- 
laxation of  the  muscle  guards  of  the  larynx. 

In  children  the  second  stage  of  anesthesia  is  most  im- 
portant. Children  are  more  susceptible  to  the  action  of 
nitrous  oxid  than  they  are  to  ether  and  many  pass  directly 
from  the  first  stage  to  profound  anesthesia.  A  child  should 
never  be  restrained  during  the  induction  of  nitrous-oxid- 
oxygen  anesthesia.  The  anesthesia  should  be  started  with 
a  mixture  containing  a  large  percentage  of  oxygen,  not 
enough  to  produce  excitement,  however,  the  percentage 
of  nitrous  oxid  being  gradually  increased  until  anesthesia  is 
secured. 

In  very  young  children  a  small  percentage  of  ether  is  given 
with  a  light  mixture  of  the  nitrous  oxid  and  oxygen,  unless 
the  child  takes  the  latter  without  the  slightest  trace  of  cya- 
nosis or  disturbance  of  respiration.  Instead  of  placing  a 
mask  over  a  child's  face  he  may  be  given  the  free  end  of  the 
gas-tube  to  play  with.  If  the  tube  be  gently  directed  to- 
wards his  nose,  he  will  soon  become  sleepy  and  will  doze  off, 
when  the  mask  may  be  applied  without  any  protest. 


ADMINISTERING    NITROTTS-OXID-OXYGEN    ANESTHESIA  231 

While  in  all  cases  restraining  and  struggling  are  carefully 
avoided,  especial  care  is  exercised  in  cases  with  serious  car- 
diac lesions — especially  fatty  degeneration.  In  these  cases 
the  anesthetist  should  be  strictly  on  his  guard  to  prevent 
strained  respiration  or  cyanosis. 

In  any  case,  after  proper  induction  the  patient's  face 
should  be  that  of  a  person  asleep,  not  of  one  under  profound 
anesthesia,  or  that  so  often  seen  in  a  dentist's  chair  when 
nitrous  oxid  has  been  administered. 

THE  MAINTENANCE  OF  ANESTHESIA  DURING  OPERATION 

At  the  completion  of  the  second  stage  of  induction  the 
eyes  are  quiet  and  the  upper  lid  may  be  raised  without  re- 
straint.  The  conjunctiva  is  never  touched.  The  swallowing 
reflex  is  absent.  The  respiration  should  be  tranquil  and 
regular,  the  rate  being  higher  than  normal,  ranging  usu- 
ally from  20  to  32,  and  being  highest  in  the  early  stages  of 
the  anesthesia.  If  the  inspiratory  rate  increases  in  response 
to  the  operative  trauma  more  nitrous  oxid  is  added  to  the 
mixture.  A  high  respiratory  rait  is  never  permitted  it  is 
kept  low  by  changing  the  mixture  of  nitrous  oxid  and  oxy- 
gen or  by  adding  some  ether-vapor. 

An  increase  in  the  respiratory  rate  with  a  return  of  facial 
expression  and  eye  reflex  means  thai  the  patient  is  coming 
<nit  nt'  the  anesthetic.     These  signs  may  be  followed  quickly 

l>\  the  ret  urn  of  the  swallowing  reflex  and  signs  of  Qausea. 

Transient  cyanosis  during  induction  cannot  always  be 
avoided     but    should   never  be  allowed  after  anesthesia   is 

established.      If  the  supply  of  oxygen  be  BUfficient,  cyanosis 

means  respiratory  obstruction  and  must  be  remedied  quickly. 

If  it  does  not  yield  to  m  mechanical  readjustment  of  the  jaw 


232  ANOCI-ASSOCIATION 

and  to  pure  oxygen,  then  the  mask  should  be  removed,  a 
wooden  mouth  gag  inserted  between  the  teeth,  the  tongue 
pulled  forward  and  respiration  re-established.  The  ex- 
perienced anesthetist  however  will  rarely  encounter  this 
emergency. 

Sometimes  with  normal  respiration  there  may  be  a  per- 
sistently slow  response  to  oxygen — a  condition  which  is  al- 
ways a  serious  matter.  If  increasing  the  oxygen  in  the  mix- 
ture does  not  clear  up  the  color  it  is  well  to  stop  nitrous  oxid 
and  give  ether  and  oxygen  for  a  few  minutes.  The  color 
should  always  be  carefully  watched.  Too  much  nitrous 
oxid  may  cause  paleness.  It  is  therefore  a  matter  of  routine 
with  us  to  diminish  the  amount  of  the  nitrous  oxid  during 
the  operation — and  towards  the  end  to  give  the  lightest  pos- 
sible mixture. 

When  it  is  necessary  to  give  ether  during  nitrous-oxid- 
oxygen  anesthesia,  it  should  be  given  gradually  so  that 
coughing  and  respiratory  spasm  may  be  avoided.  In  chil- 
dren the  mucous  membrane  is  very  susceptible  to  ether,  as 
it  is  in  heavy  smokers.  Coughing  and  irritation  of  the 
mucous  membranes  delay  the  operation  and  tire  the  patient. 

During  the  harder  phases  of  difficult  operations  on  the 
biliary  passages  and  deep  in  the  pelvis,  in  rigid,  fat,  or  re- 
sistant patients,  nitrous-oxid-oxygen  may  not  give  sufficient 
relaxation.  In  such  cases  ether-vapor  is  added  until 
sufficient  relaxation  has  been  secured,  when  the  ether  is  dis- 
continued and  the  patient  carried  through  the  remainder  of 
the  operation  on  nitrous-oxid-oxygen  alone.  At  the  end  of 
the  operation  these  patients  will  experience  neither  the 
odor  nor  the  taste  of  ether.  In  all  cases  the  surgeon  should 
co-operate  with  the  anesthetist  by  warning  her  in  advance 


ADMINISTERING    NITROUS-OXID-OXYGEN    ANESTHESIA     233 


Fig    55      Nitroi    -Oxid-Oxygen    Vnebthesia.     Patient   in    Dqbsal 

Posn  ion, 


ADMINISTERING    NITROUS-OXID-OXYGEN    ANESTHESIA      235 


Fig.  56      Nitrous-Oxid-Oxygen    \\i-hh-i\.     Patient  in  Lateral 
Po  ition     Mask  linn  i\  Placi    hi   Linen  Cloth. 


ADMINISTERING    NITROTJS-OXID-OXYGEN    ANESTHESIA     237 


Fid.  .".7. 


NTlTBOUS-OxiD-OXYQEN     ANESTHESIA.       PATIENT  IN    PHONE    P08I- 

noN,  Ma8b  Held  i\  Place  bi    Linen  Cloth. 


ADMINISTERING    NITROUS-OXID-OXYCEX    ANESTHESIA      239 

when  he  is  ready  to  dislodge  a  tumor  or  about  to  perform 
any  other  especially  stimulating  manipulation. 

POSITION  OF  THE  PATIENT  DURING  ANESTHESIA 

It  is  our  rule  to  anesthetize  all  patients  in  the  dorsal  posi- 
tion (Fig.  55),  the  change  to  any  position  demanded  by  the 
operation  being  made  after  the  patient  is  asleep.  As  in 
ether  anesthesia,  especially  if  the  patient  be  fat  or  have  any 
cardiac  lesion,  the  change  to  the  Trendelenburg  position 
should  be  made  gradually  and  not  until  even  respiration  and 
good  color  have  been  established. 

The  lateral,  lateral  prone  and  prone  positions  are  always 
difficult  for  the  anesthetist,  especially  with  nitrous  oxid  and 
oxygen.  The  difficulty  of  holding  the  mask  securely  enough 
to  exclude  air  and  of  maintaining  a  proper  position  of  the 
hand  may  be  a  great  strain.  The  first  of  these  difficulties 
may  be  largely  overcome  by  passing  a  linen  cloth  behind  the 
mask  and  securing  it  in  position  with  hemostats  (Figs.  56 
and  57).  When  properly  adjusted  this  will  hold  the  mask 
Becurely  and  will  completely  exclude  outside  air.  It  re- 
quires practice  however  to  adjust  it  properly.  The  arms 
are  supported  by  Bevan's  euffs. 

The  loss  of  bodily  he;it    i>  negligible  in   oitrOUS-Oxid-OXy- 

gen  anesthesia,  being  much  less  than  in  ether  anesthesia,  and 
Bweating  is  rarely  -ecu  in  the  anodated  operation.  The  pa- 
tient, however,  is  well  protected  during  the  operation  when  he 
lies  on  ;i  warm  water-bed,  and  on  his  return  trip  t<»  the  ward, 
before  which  fresh  warm  clothes  are  put  on. 

Transitory  nausea  and  sometimes  vomiting  may  occur 
Immediately  after  the  operal ion. 


240  ANOCI-ASSOCIATION 

TECHNIQUE  FOR  SPECIAL  OPERATIONS 
EXOPHTHALMIC  GOITER 

Nitrous-oxid-oxygen  anesthesia  is  especially  advantageous 
for  patients  with  exophthalmic  goiter,  for  the  quick  loss  of 
consciousness  is  an  important  factor  in  these  cases  and  the 
dangerous  excitement  experienced  when  going  under  and 
coming  out  from  ether  anesthesia  is  avoided.  Our  method 
is  to  give  the  patient  daily  " inhalation  treatments"  for  sev- 
eral days  before  the  operation.  From  a  few  whiffs  of  oxygen 
and  a  little  conversation  we  gradually  increase  the  amount 
of  nitrous  oxid  in  the  mixture  until  the  day  before  the  op- 
eration, when  the  patient  is  put  to  sleep  without  any  diffi- 
culty. To  test  the  heart  in  especially  bad  risks  a  trial  anes- 
thesia of  about  ten  minutes  is  given.  The  patient  does  not 
realize  that  he  has  been  anesthetized  but  believes  that  he 
has  fallen  asleep  during  his  "treatment." 

On  the  morning  of  the  operation  the  "  inhalation  treat- 
ment" is  given  once  more,  and  when  completely  anesthetized 
the  patient  is  carefully  lifted  from  his  bed  to  the  operating- 
room  cart.  One  orderly  takes  charge  of  the  cart,  another  of 
the  gas  machine.  A  physician  and  a  nurse  accompany  the 
anesthetist,  so  the  patient  is  safeguarded  on  all  sides.  When 
the  operating  room  is  reached  the  patient  is  gently  lifted  to 
the  operating  table  and  the  anesthetic  apparatus  is  changed 
for  the  permanent  one  belonging  to  the  operating-room  equip- 
ment. The  patient  is  then  prepared  for  the  operation.  As 
every  step  is  taken  with  deliberation  and  gentleness  there  is 
little  disturbance  of  the  anesthesia. 

After  the  conclusion  of  the  operation  the  patient  is  kept 
asleep  until  he  has  been  taken  back  to  his  room, — the  ar- 


ADMINISTERING    NITROUS-OXID-OXYGEN    ANESTHESIA  241 

rangement  of  which  is  exactly  as  it  was  before  he  fell  asleep. 
When  the  patient  awakes  only  the  anesthetist  and  attend- 
ing nurse  are  present.  The  amount  of  information  given 
him  depends  entirely  on  the  case.  Usually  however  he  is 
reassuringly  told  that  the  operation  is  over. 

The  management  of  a  bad  casi  of  exophthalmic  goiter 
is  usually  difficult.  In  addition  to  the  unstable  nervous 
system  there  is  often  an  impaired  heart.     These  patients 


In.      58.       NlTBOUB-OxXD-OxYQEN      \  \  1.- i  m.-i  \,     SHOWING     USB     "I      NASAL 

Tubes  in  Pace,  Mouth  \m>  Neck  Operations. 


are  sometimes  erratic  in  their  response  to  the  anesthetic  and 
may  show  marked  resistance  in  the  second  stage.  In  those 
cases  of  exophthalmic  goiter  in  which  there  are  degenerative 
changes  in  the  heart  muscle  it  is  vitally  essential  to  keep  the 
respiration  tree  from  strain  and  to  maintain  the  lightest 
p<  tssible  anesl  hesia. 

16 


242  ANOCI-ASSOCIATION 

SURGICAL  SHOCK  AND  COLLAPSE 

In  patients  suffering  from  shock  and  collapse,  as  in  ac- 
cident cases,  the  very  gradual  adjustment  of  the  anesthetic 
is  most  important  and  the  utmost  care  must  be  taken  to 
establish  a  comfortable  free  respiration.  Here  also  the 
lightest  possible  anesthesia  is  maintained,  as  the  surgeon  uses 
local  anesthesia  and  wishes  to  be  aware  of  any  response  that 
the  patient  may  make  to  the  trauma  that  he  may  extend  the 
local  anesthetic  protection. 

FACE,  MOUTH  AND  NECK  OPERATIONS 

In  operations  on  the  face,  mouth  or  neck  in  which  the 
mask  interferes  with  the  operation,  nasal  tubes  are  used 
(Fig.  58) .  The  patient  is  first  put  to  sleep  with  nitrous-oxid- 
oxygen  and  then  enough  ether-vapor  is  added  to  secure  the 
necessary  relaxation  for  the  insertion  of  the  nasal  tubes. 
By  means  of  a  glass  tube  these  are  connected  with  the  rubber 
tubing  which  extends  to  the  gas  machine.  An  expiratory 
valve  is  of  course  a  necessary  adjunct.  The  mouth  is  care- 
fully packed  and  watchful  care  is  exercised  to  prevent  kink- 
ing in  the  tube.  After  the  insertion  of  the  nasal  tubes,  the 
patient  can  usually  be  carried  through  the  operation  without 
the  addition  of  ether-vapor. 

LARYNGECTOMY 

The  patient  is  anesthetized  in  the  usual  way  until  the 
trachea  is  opened.  A  long  rubber  tube  attached  to  the  gas 
apparatus  is  then  inserted  into  the  trachea.  The  tracheal 
connection  is  made  air-tight  by  means  of  gauze  packing, 
which  also  prevents  the  entrance  of  blood  and  mucus. 


ADMINISTERING    NITROUS-OXID-OXYGEN    ANESTHESIA  243 

BRAIN  OPERATIONS 

In  brain  operations  a  calm  and  free  respiration  is  main- 
tained by  the  use  of  nitrous-oxid-oxygen.  As  little  pres- 
sure as  possible  is  used  to  prevent  venous  congestion  and 
increased  bleeding.  A  light  administration  of  nitrous-oxid- 
oxygen  is  usually  sufficient  to  maintain  the  above  condi- 
tions, but  it  may  be  necessary  in  some  cases  to  diminish 
the  nitrous  oxid  and  add  ether-vapor. 

TONSILS  AND  ADENOIDS 

In  the  removal  of  tonsils  and  adenoids  we  still  use  ether 
or  ether-vapor. 

ACUTE  INFECTIONS 

In  these  cases  we  try  to  avoid  the  use  of  any  ether-vapor— 
even  if  the  time  needed  to  establish  anesthesia  is  prolonged. 
These  patients  are  prone  to  vomit  in  any  ease,  a  tendency 
which  is  increased  by  the  lack  of  preoperative  preparation 
as  these  arc  emergency  cases.     Some  excitement  may  occur 

in   the  second   stage      hut    as  ;i    rule   these   patients  do  well 
under  nit rous-oxid-oxygen. 

OPERATIONS  ON  THE  THORAX 

Clinical  judgment  is  necessarily  required  in  the  use  "i 
positive  pressure  in  a  machine  which  is  not  equipped  with 
a  manometer,  whereby  the  pressure  may  be  accurately  re- 
corded. In  one  of  the  machines  in  use  in  our  clinic  the 
Teter  positive  pressure  to  from  I  mm.  to  8  nun.  may  he 
obtained  by  the  use  <  >t  the  expiratory  valve.  Dr.  Teter  con- 
siders that  from  s  mm.  to  hi  nun.  i-  sufficient  for  cases 
requiring  positive  pressure,  while  1  mm.  i-  sufficient  to 
maintain  the  depth  of  anesthesia  in  an  ordinary  case. 


244  ANOCI-ASSOCIATION 

In  our  other  machine  (the  Monovalve)  the  technique 
by  which  the  pressure  is  governed  depends  almost  entirely 
upon  clinical  experience.  The  breathing  bag  is  as  near  the 
face  mask  as  is  convenient  and  the  pressure  in  the  bag  is 
regulated  by  means  of  a  light  expiratory  valve.  In  ordinary 
work  the  bag  is  evenly  and  lightly  distended  but  is  not  taut 
at  the  end  of  an  ordinary  expiration.  The  pressure  in  the 
bag  may  vary  from  one  mm.  to  four  or  five.  Whatever 
pressure  gives  a  free  unembarrassed  respiration  is  clinically 
the  best  pressure  for  that  case.  The  respiration  will  quickly 
show  the  effect  of  too  much  pressure. 

When  positive  pressure  is  required  within  the  thoracic 
cavity,  we  endeavor  to  increase  the  pressure  by  closing  the 
expiratory  valve,  thus  holding  the  bag  taut.  The  amount  of 
pressure  secured  in  this  way  cannot  at  present  be  accurately 
given.  It  has  been  sufficient,  however,  to  prevent  collapse 
of  the  lung  in  the  cases  in  which  we  have  used  it. 

ANALGESIA 
We  have  used  nitrous-oxid-oxygen  to  produce  analgesia 
in  minor  operations  on  patients  who  desired  to  return  home 
immediately  after  the  operation,  and  who  would  resist  the 
anesthesia  if  entirely  unconscious,  so  that  increased  anes- 
thesia would  be  required  to  overcome  the  resistance.  These 
patients  were  talked  to  throughout  the  operation,  and  at 
the  slightest  evidence  of  pain  were  told  if  they  would  draw 
a  long  breath  the  pain  would  disappear.  Deep  breathing  and 
the  consequent  resistance  indicate  that  the  anesthesia  is 
becoming  too  deep.  This  is  overcome  promptly  by  discon- 
tinuing the  gas  for  a  moment  and  by  increasing  the  per- 
centage of  oxygen.  The  amount  of  oxygen  should  be  gov- 
erned carefully,  as  too  much  may  excite  the  patient. 


ADMINISTERING    NITROUS-OXID-OXYGEN    ANESTHESIA  24.") 

SUMMARY 

Dr.  Teter,  my  associates  at  Lakeside  Hospital,  and  I  have 
administered  nitrous-oxid-oxygen  for  general  anesthesia 
34,964  times  without  an  anesthetic  fatality.  We  consider 
the  use  of  nitrous-oxid-oxygen.  with  the  addition  of  ether- 
vapor  when  necessary,  a  practical  and  safe  anesthetic  for  the 
work  of  a  large  surgical  clinic. 

In  this  clinic  there  is  no  prejudice  againsl  the  use  of  ether- 
vapor,  but  we  endeavor  to  use  it  only  when  it  adds  to  the 
efficiency  of  the  anesthetic.  In  other  words,  we  advocate 
that  combination  of  anesthetics  which  will  produce  the 
safest  and  best  anesthesia  possible  for  each  particular  case. 

In  the  clinic  we  work  under  ideal  conditions.  The  sur- 
geons by  their  careful  and  gentle  manipulations  dming  the 
operation,  help  the  anesthetist  to  secure  a  tranquil,  quiet 
anesthesia  and  to  keep  the  general  tone  of  the  patienl  up 
to  <>ur  standard. 

The  fundamental  necessity  is  for  the  anesthetic  to  cover 
the  hurt.  The  greater  the  hurt,  therefore,  the  greater  is  the 
amount  of  anesthel  ic  required. 

In  this  clinic,  nitrous-oxid-oxygen  is  given  only  by  anes- 
thetists who  have  had  a  good  preliminary  training  and  ex- 
perience in  the  administration  of  ether  anesthesia,  and  who 
are  also  specially  trained  in  the  use  of  nitrous-oxid-oxygen. 

The  ideal  method  by  which   the  nitrous  oxid  and  oxygen 

are  supplied  to  the  operating  pavilion  in  Lakeside  Hospital, 
is  .'mother  factor  which  contributes  greatly  to  the  efficiency 
of  the  anesthetist. 


ANOCI-ASSOCIATION  IN  ITS  RELATION  TO  THE 

PREOPERATIVE  AND  POSTOPERATIVE 

CARE  OF  PATIENTS 

BY  SAMUEL  L.  LEDBETTER,  JR.,  M.D. 

Resident  Surgeon,  Lakeside  Hospital 

PREOPERATIVE  CARE 

The  principle  of  anoci-association  is  carried  out  not  only 
in  the  operating  room,  but  is  applied  from  the  moment  that 
the  patient  enters  the  hospital.  As  fear  diminishes  the  pa- 
tient's power  of  resistance,  he  should  be  received  on  his  en- 
trance into  the  hospital  with  cheerfulness  and  kindness,  for 
a  quiet  and  cheerful  atmosphere  will  do  more  to  dispel  his 
fears  than  will  all  the  verbal  encouragement  that  can  be 
given.  In  a  few  words,  the  patient  should  be  made  to  feel 
that  he  is  to  be  well  cared  for  and  that  he  will  suffer  no  un- 
pleasant experiences.  This  duty  belongs  for  the  most  part 
to  the  nurses  and  the  house-officers,  who  while  taking  the 
history  and  making  the  routine  physical  examination  can 
do  much  to  obtain  the  confidence  of  the  patient. 

In  our  practice  here  in  the  Surgical  Service  of  the  Lake- 
side Hospital,  it  is  our  endeavor  always  to  exalt  the  pa- 
tient's viewpoint. 

The  preoperative  preparation  should  be  flexible.  If  the 
patient  be  sleepless  during  the  night  before  operation,  he 
should  be  given  a  sedative.  We  all  know  from  our  own  ex- 
periences the  depressed  physical  state  produced  by  a  sleep- 
less night,  surely  an  unfavorable  state  for  an  operation. 

On  the  day  of  operation  it  is  our  custom  to  administer  to 
strong  adult  patients  a  hypodermic  dose  of  morphia,  gr.  ^, 

246 


PREOPERATIVE    AND    POSTOPERATIVE    CARE    OF    PATIENTS   247 

and  scopolamin,  gr.  T:-)(),  about  one  hour  before  the  patient 
goes  to  the  operating  room.  The  aged,  the  young,  and  the 
debilitated  receive  very  little  if  any  sedative. 

The  preliminary  medication  serves  two  purposes:  First, 
it  helps  to  do  away  with  fear  on  the  part  of  the  patient,  so 
that  he  goes  to  the  operating  room  quietly:  and,  secondly, 
he  relaxes  into  anesthesia  much  more  easily.  We  have  yet 
to  see  an  unfavorable  result  following  this  preliminary  med- 
ication. 

On  entering  the  operating  room  the  patient  should  be 
gently  placed  upon  the  table  and  absolute1  quiet  should  pre- 
vail until  he  is  under  the  influence  of  the  anesthetic. 

POSTOPERATIVE  MANAGEMENT  OF  CASES  IN  GENERAL 

Patient-  are  taken  back  to  their  rooms  quietly,  and, as  a 
rule,  unless  contraindicated,  are  made  comfortable  on  four 
or  five  pillows  in  a  semi-sitting  posture. 

We  encourage  our  patients  to  move  about  in  bed,  to  turn 
frequently,  and  as  a  rule  allow  them  to  sit  up  fairly  early. 
This  increases  (he  general  tone  of  the  patient  and  helps  t<> 
prevent  pulmonary  complications  and  phlebitis. 

Wry  elderly  individuals  on  account  of  the  senile  changes 
in  their  circulation  are  usually  placed  Hat  in  bed  foi  ;i  few 
hours  .it'tcr  operation,  as  the  >ittin<j;  posture  immediately 

after  operation  may  cause  Bufficienl    anemia  <>l'  the  brain  t<> 

produce  an  increase  of  the  pulse-rate.  After  :i  few  hours, 
however,  they  are  encouraged  to  sit  up.  to  move  aboul  fre- 
quently and  within  two  or  three  days  are  usually  allowed  to 

sit    up  in  a   chair.      Cases  <•!    inoperable  cancel-,   particularly 

those  with  cancer  of  the  abdominal  viscera,  .-ne  often  out  of 
bed  t he  -el' Hid  day  after  opera! ion. 


248  ANOCI-ASSOCIATION 

After  major  operations  it  is  our  rule  to  give  to  all  cases 
rectal  tap  water  containing  glucose  and  sodium  bicar- 
bonate, one  ounce  of  each  to  the  quart.  We  usually  ad- 
minister the  solution  by  the  Murphy  drop  method,  but  in 
case  it  is  not  retained  it  is  given  in  bulk,  200  c.c.  every  two 

hours. 

SEDATIVES 

After  the  anociated  operations  there  is  very  little  post- 
operative pain.  The  prognosis  may  depend  largely,  however, 
upon  the  comfort  of  the  patient  after  the  operation.  If 
there  be  pain  or  restlessness  we  use  morphia,  usually  in  gr.  | 
or  3<t  doses.  Everything  is  done  to  give  the  patient  a  good 
rest  on  the  night  after  the  operation. 

Morphia  is  rarely  required  routinely  for  more  than  from 
twelve  to  twenty-four  hours.  An  enema  is  usually  given 
on  the  second  morning  and  at  any  time  should  there  be  flat- 
ulence. 

NOURISHMENT 

As  nausea  very  rarely  occurs,  most  patients  except  gas- 
tric cases  begin  to  take  water  very  soon  after  the  operation. 
Even  if  there  be  nausea  water  in  large  amounts  may  be 
given.  After  simple  laparotomies,  not  involving  resections 
or  anastomoses,  when  there  is  no  nausea,  the  patient  is  us- 
ually given  liquids  without  milk  even  on  the  day  of  opera- 
tion. On  the  following  day  the  patient  is  encouraged  to 
take  a  little  soft  food,  the  amount  being  increased  rapidly 
until  the  third  or  fourth  day,  when  he  receives  a  fairly  liberal 

diet. 

STIMULATION 

Stimulants   are    not    administered   excepting   in    certain 

cardiac  cases  when  the  patient  may  be  given  camphorated 

oil  or  digitalis. 


PREOPERATIVE    AND    POSTOPERATIVE    CARE    OF    PATIENTS    249 
PREOPERATIVE  AND  POSTOPERATIVE  CARE  IN  SPECIAL  CASES 

ACUTE   INFECTIONS 

Patients  with  acute  infections  are  prepared  as  are  other 
cases,  excepting  those  with  infections  of  the  peritoneal  cav- 
ity, when  all  catharses  and  enemata  arc  withheld. 

After  an  operation  for  acute  appendicitis,  for  peritonitis, 
etc.,  the  patient  is  placed  in  an  exaggerated  Fowler  position 
and  is  given  rectal  tap  water.  Large,  hot  flannel  packs  are 
placed  over  the  entire  abdomen,  going  well  up  on  to  the 
chest  and  around  the  sides  to  the  bed  line.  These  are 
changed  every  two  hours.  The  patient  is  allowed  to  drink 
all  the  water  that  he  wishes,  and  is  given  by  mouth  sodium 
bicarbonate  solution,  one  dram  to  the  glass.  At  regular 
intervals  morphia  is  given  in  sufficient  doses  to  control  the 
pulse  and  respiration. 

CHOLECYSTITIS 

In  cases  of  gangrene  and  rupture  of  the  gall-bladder,  the 
postoperative  care  is  the  same  as  in  acute,  suppurative  ap- 
pendicitis cases,  i.  e.,  hot  packs  and  morphia,  excepting  that 
instead  of  placing  these  patients  in  the  Fowler  position  we 
keep  them  in  a  recumbent  position  on  the  right  side. 

EXOPHTHALMIC  GOITER      PREOPERATIVE  CARE 

The  utmost  tact  and  skill  are  required  in  the  treatment 
of  a  patient  with  exophthalmic  goiter,  tie  is  made  as  com- 
fortable  as   possible,    great    pains   being  taken   to   insure 

absolute   quiet,    and  he   is   kept  in   the  open  air  a-  much  as 

possible.     To  allay   nervousness  and  improve  the  general 

condition  <>!'  the  patient,  sponge  baths  are  given  frequently. 

\  sedative    usually  -odium  bromid.  from  30  to  50  grains. 


250  ANOCI-ASSOCIATION 

three  times  a  day — helps  to  secure  repose.  It  is  our  rule 
never  to  tell  the  patient  the  exact  date  of  the  operation.  At 
about  8.30  each  morning  one  of  our  anesthetists  visits 
him  and  gives  him  an  " inhalation  treatment."  At  first 
the  anesthetist  may  give  just  a  little  oxygen,  with  possibly 
a  whiff  or  two  of  nitrous  oxid.  This  is  kept  up  for  several 
days,  the  patient  being  given  a  little  more  nitrous  oxid  each 
day,  until  once  or  twice  he  may  become  completely  anes- 
thetized. After  his  "inhalation  treatment"  the  patient 
usually  feels  much  better  and  relaxes  into  a  sleep.  About 
nine  o'clock,  or  after  receiving  the  " inhalation,"  the  patient 
is  given  his  breakfast.  After  several  days  in  the  hospital, 
when  the  patient  has  become  quiet  and  is  considered  a  fav- 
orable operative  risk,  morphia,  gr.  -g-,  scopolamin,  gr. 
3lro >  is  given  hypodermically,  the  dose  being  repeated  in 
one-half  hour.  The  patient  is  then  anesthetized  in  his 
room  without  his  knowledge,  thinking  that  he  is  receiving 
only  the  usual  "inhalation  treatment."  If  the  patient  is 
still  restless  after  being  anesthetized,  another  hypodermic 
dose  of  morphia,  gr.  g-,  is  given.  In  the  rare  cases  in  which 
this  does  not  quiet  him  sufficiently  'the  operation  is  post- 
poned. If  the  patient  is  quiet  he  is  conveyed  to  the  operat- 
ing room  while  under  the  anesthetic  and  the  usual  anociated 
operation  is  carried  out.  In  some  cases  we  give  mor- 
phia on  the  table,  repeating  the  dose  until  the  patient  be- 
comes absolutely  quiet  with  even  and  regular  respirations. 
In  cases  with  the  nausea  and  vomiting,  which  we  some- 
times see  with  acidosis,  the  patients  are  given  a  glucose  and 
sodium  bicarbonate  solution  per  rectum  and  infusions  before 
the  operation,  which  is  deferred  until  the  acetone  and  di- 
acetic  acid  have  disappeared  from  the  urine. 


PREOPERATIVE    AM)    POSTOPERATIVE    CAKE    OF    PATIENTS    251 
EXOPHTHALMIC   GOITER— POSTOPERATIVE   CARE 

The  patient  is  taken  back  to  his  room  while  under  the  an- 
esthetic and  is  allowed  to  wake  up  slowly.  The  manage- 
ment of  the  anesthetic  has  been  described  minutely  in  the 
chapter  OD  Anesthesia.  The  patient  is  put  in  a  comfortable 
position,  an  ice  pack  is  placed  over  the  heart,  and  tepid 
sponge  baths  are  given  every  four  hours.  If  the  patient  be 
very  restless  his  hands  and  face  are  constantly  sponged  with 
ice  water.  Sodium  bicarbonate  and  glucose  solution  is  given 
per  rectum.  Morphia  is  given  frequently  enough  and  in 
sufficient  doses  to  keep  the  patient  quiet.  If  a  reaction  oc- 
cur,— rarely  in  less  than  twenty-four  hours  after  the  opera- 
tion,— the  restlessness  is  again  controlled  by  sponging  with 
ice  water  and  by  morphia.  After  the  first  two  or  three 
days  morphia  is  rarely  uecessary.  We  then  give  other 
sedatives,  usually  bromid  of  sodium.  30  grains,  three  times 
a  day. 

The  patient  is  allowed  from  the  first  to  have  as  much 
nourishment   as  he  will  take.      lie  is  kepi   quiet   and  out   of 

doors  as  much  as  possible.  The  outcome  of  these  cases  de- 
pends upon  the  exclusion  of  traumatic  and  psychic  stimuli 
at  the  time  of  operation,  and  on  keeping  the  patient  quiet 
after  operation.  Even  if  the  pnl>e-rate  should  increase 
after  the  operation  the  prognosis  is  good  in  any  case  if  the 

patient  be  quiel  and  if  there  be  no  acidosis.  If  acidosis 
occur  it  is  combated  by  glucose  and  sodium  bicarbonate  solu- 
tion per  rectum,  carbonate-  by  month,  and  as  nineh  nourish- 
ment  as  can  be  taken. 


A   HOSPITAL   PLANT   FOR  THE   MANUFACTURE   OF 
NITROUS  OXID 

BY  A.  R.  WARNER,  M.D. 

Superintendent,   Lakeside  Hospital 

Lakeside  Hospital  has  manufactured  most  of  the  nitrous 
oxid  used  in  the  hospital  for  about  four  years,  and  during  this 
time  gas  has  been  purchased  only  on  days  of  unusual  con- 
sumption and  during  breakdowns  in  the  manufacturing  plant. 

Through  the  generosity  of  Mr.  H.  M.  Hanna,  one  of  the 
trustees  of  Lakeside  Hospital,  it  has  been  possible  to  run  the 
hospital  plant  experimentally  for  the  past  year  (1)  to  find 
how  the  safest  possible  nitrous  oxid  for  anesthetic  use  can 
be  made  and  (2)  to  develop  a  mechanical  plant  by  which 
nitrous  oxid  may  be  surely  and  safely  manufactured  under 
usual  hospital  conditions  and  limitations.  During  this  ex- 
perimentation there  have  been  frequent  changes  in  the  form 
of  apparatus  and  in  the  materials  used  in  the  generation  and 
purification  of  the  gas.  This  experimental  work  is  not  fin- 
ished and  the  plant  is  changed  in  some  particular  very  fre- 
quently. The  accompanying  diagram,  therefore  (Fig.  59), 
can  give  but  a  general  idea  of  the  process  of  manufacture. 
In  the  actual  plant  the  apparatus  is  arranged  around  three 
sides  of  a  room  in  the  basement;  but  to  make  the  diagram 
as  simple  as  possible  it  is  shown  here  in  a  straight  line.  The 
diagram  indicates  that  but  one  washing  is  done  in  a  tower, 
but  it  is  probable  that  we  shall  soon  substitute  a  stoneware 
tower  for  one  of  the  washing  jars.  However,  plants  of 
small  capacity  will  probably  always  use  these  or  other 
special  jars  for  certain  washings. 

252 


•WATER     FOR     CLEANING    TANKS  ^ 


Manufacture  of  Nitrous  Oxid. 


HOSPITAL  PLANT  FOP,  MANUFACTURE  OF  NITROUS  OXID    253 


4 

in 

U 

D 

X 

z 

9) 

E 

n 

< 

1 

5 

1 

x:   2 


- 
i 

% 

2 

3 

- 


- 


254  ANOCI-ASSOCIATION 

The  storage  tanks  have  proved  just  as  useful  whenever 
we  have  purchased  gas  as  when  we  have  made  it.  To  avoid 
interruptions  from  freezing  or  from  the  varying  pressures 
and  rates  of  flow  from  the  cylinders  we  arranged  an  inlet  to 
our  tanks  at  which  we  connect  the  cylinders  of  purchased 
gas.  The  lowest  price  can  be  secured  on  the  large  (3,200 
gal.)  cylinders,  so  we  have  always  purchased  these.  A  re- 
ducing valve  set  at  a  safe  pressure  for  the  tank  is  inserted 
between  the  cylinder  and  the  tank  and  protects  the  latter 
from  high  pressures  and  makes  it  possible  to  leave  the  cylin- 
der attached  all  day  or  over  night.  When  the  tank  is  full, 
the  flow  is  automatically  cut  off.  A  reducing  valve  on  the 
tank  controls  the  pressure  delivered  through  the  main  line 
to  the  operating  rooms.  Another  reducing  valve  at  the 
outlet  in  the  operating  room  gives  the  anesthetist  control  of 
the  pressure  needed  in  the  machine  which  is  in  use  (Fig.  60) . 

The  advantages  of  this  system  of  tanks,  valves,  and  pipes 
to  the  operating  rooms  are  briefly  as  follows :  the  gas  is  de- 
livered to  the  mixing  machine  and  to  the  patient  at  any 
desired  pressure  and  with  a  uniform  rate  of  flow;  there  are 
no  interruptions  in  the  flow  of  gas;  the  large  cylinders 
can  be  used,  thus  saving  a  third  of  the  cost  of  the  gas ;  the 
gas  reaches  the  patient  at  room  temperature,  not  at  the  very 
low  temperature  of  gas  direct  from  cylinders;  the  time  of 
attendants  is  not  required  to  change  small  cylinders  and 
the  need  for  keeping  large  or  small  cylinders  in  the  operating 
room  is  avoided.  All  these  advantages  are  secured  by  the 
manufacture  of  the  gas  in  the  hospital  and  the  tanks  were 
originally  considered  a  part  of  the  manufacturing  plant,  but 
attention  is  directed  to  the  advantage  of  these  storage  tanks 
in  overcoming  the  objections  to  the  use  of  cylinders  in  the 
operating  room. 


INDEX 


Abdomen,    acute    infections    of    the 

upper,  151 
Abdominal  infections,  acute,  l  hi.  L52 
operations,  anesthetic  to  be  used 
in,  122,  L31,  I  17 
biologic  consideral  ions  in,  122 
genera]  technique  of,  L26 
novocain  in,  L26 
Accident  cases,  general  considerations 
in,  204 
morphin  in,  205 
Acidosis    after   stomach    operations, 
139 

Adrenalin.  OUtpul    of,  effect  of   drills 
cm,    67 

of  emotional  -hock  on,  -—» » "» 

of  lis  pertension  on,  208 

df  morphii]  mi.  'i7 

df  Btrychnin  mi.  » ">7" 

df  toxic,   foreign   proteid   ami 

aiiaphvlact  ic  shock  mi.  •  > 7" 

Alypin  in  bladder  operal  ions,  158 

in  prostatectomy,  L59 
Amputations,  anesthetic  to  Ik-  used 
in,  203 
technique  of,  203 
transfusion  of  blood  in.  204 
Analgesia    produced    by  uitrous-oxid 

oxygen,  2  1 1 
Anilnu -  needle  bolder,  1 56 
Anemia     df     the     brain,    brain-cell 
changes  due  to,  68 
mean-  (if  <i\ ercoming,  106 
Anesthesia,  induction   of,  lii-t  siajje, 
227 
in  acute  infect  ions,  2 13 
in  brain  operation! 
m  children,  230,  228 


Anesthesia,   induction  of,  in  exoph- 
thalmic goiter,  2 1<> 

in   face  operal  ion-.   _'  12 

in  laryngectomy,  242 

in  mouth  operation-.  2  1_' 

in  neck  operations.  2  12 

in  operat  ions  on  i  he  thorax,    _'  !•! 

mi  the  tonsils,  2 hi 
in  surgical  shock  and  collapse, 

position  of  pai icni  during,  239 

second   -lace,   228 

local,  iii  abdominal  operations,  125 
maintenance  of,  during  operation, 

231 
spinal,  in  abdominal  operations,  125 
Anesthetics,   combination    of,  under 
anoci-association,  109 
general,  protection  by,  109 
inhalation,  choice  of,  79,  1 16 
elTecl  of  -hock  under.  77 

of  trauma  under.  80 
motor  mechanism  under,  sl 
local,  protect  ion  by,  109 
tager,  effecl  mi  bodj  mechanism,  '.'."j 
Appendectomy,  technique  in.  l  i^ 
Appendicit i-.  acute,  l  17 
morphin  in,  150 
nitrous-oxid-oxygen  in,  1 18 
postoperative  care  in,  1  19,  2  19 
\-ept ic  wound  fever,  217 
Au-tin.  .1    B  .  24 


B  \'    R  \(   111   .    pii-!(i|ielall\  e.    219 

Bartlett,  155 

uffs,  239 
Bladder  opera!  ions,  168 


256 


INDEX 


Blood,  H  ion  concentration  of,  24 
Bloodgood,  10S,  145,  201,  221 
Bottomley's  method,  114 
Brain,  operations  on,  199 
Brain-cells,  effect  on,  of  anemia,  68 

of  drugs,  67 

of  emotions,  56 

of  hypotension,  211 

of  low  blood-pressure,  68,  73,  106 

of  morphin,  67 

of  shock,  34 

under    inhalation   anesthetics, 
77 

of  strychnin,  67 

of    toxic,    foreign    proteid,    and 
-anaphylactic  shock,  67 

of  traumatic  shock,  49 
Breast,  cancer  of,  201 
Brown,  John  Young,  205 


Cabot,  221 

Cancer  after  gastric  ulcer,  139 

of  the  breast,  201 

of  the  larynx,  179 

of  the  rectum,  174 

of  the  stomach,  174 

of  the  tongue,  181 

of  the  uterus,  175 
Cholecystectomy,  133,  134 
Cholecystostomy,  133,  134 
Clark,  Alonzo,  150 
Clark,  John  G.,  155 
Codman,  221 
Coffey  operation,  157 
Common  duct  operations,  134 
cause  of  death  in,  135 
technique  in,  136 
Curare,  effect  of  trauma  under,  50 

on  the  motor  mechanism,  81 
Cushing,  199 


Deaver,  147 
Dolley,  D.  H.,  24 
Duodenal  ulcer,  139 


VON  ElSELSBERG,   174 

Emotional   factor   in   surgical   opera- 
tions, 209 
Emotions,  effect  on  the  body  mechan- 
ism, 94 
explained  on  the  mechanistic  basis, 
96 
Ether    anesthesia,    effect    of    shock 
under,  77 
of  trauma  under,  50 
for  alcoholics,  229 
in    abdominal    operations,    122, 

131 
in    acute    abdominal    infections, 

146 
in  cases  of  hypertension,    210 
in  operations  for  cancer  of    the 

uterus,  177 
in  resection  of  the  intestines,  140 
Exhaustion,  cause  of,  31 

definition  of,  32 
Exophthalmic  goiter,  190 

administration    of    nitrous  oxid 

oxygen  in,  240 
preoperative  care  in,  249 
technique  of  operation  for,  192 


Fear,  its  effect  on  bodily  functions, 

94,  97 
Flint,  150 

Fowler  position,  115,  148 
Frazier,  199 
Frazier's  method,  200 


Gall-bladder,  operations  on,  132 

technique  of,  133 
Gas-pains,  postoperative,  213 
Gasserian  ganglion,  200 
Gastrectomy,  139,  174 
Gastric  ulcer,  139 
Gastroenterostomy,  139,  174 
Goiter,  exophthalmic,  190 
Graves'  disease,  190,  207,  217 

technique  of  operation  for,  192 


INDEX 


257 


Halstead  forceps,  196 

hemostats,  143 
Hanna.  II.  M..  252 
Herniotomy,  142 

technique  in,  143 
H-ion  concentration,  2 1 
Hodgins,  Miss  Agatha,  L16,  226 
Horaley,  L99 
Hypertension,  cause  of,  206 

a  principle  of  biologic  adaptation, 
208 
Hyperthyroidism,  postoperative,  198, 

217 
Hypotension,  210 


Lnfei  noNB,  acute  abdominal,  1  16 
biologic  protecl  ion  in,  89 
of  the  upper  abdomen,  1"  1 

pelvic,    152 

postoperal  ive,  219 


.ll.  ii   NOSTOMY,    1  -  1 

l\i  i.i.v  needle,  156,  157 
Kidney  operations,  technique  in,   160 
Kinetic  theory  of  shock,  29,  31,  34, 
1 1  ii  i 

evolution  <>f,  1 9 

foundation  of,  25 

technique  necessitated  by,  120 
Knott,  Vim  Buren,  l  18 


Labi  \<.i.<  rom .  i^o 
Larynx,  cancer  of,  179 
Ledbetter,  Samuel  L  .  Jr  .  246 
Lilienthal,  173 

Liver,   bistologic  changes,   cau 
32 
due  i"  shock,  1 1 
due  to  toxic,  foreign  pi 
and  anaphylacl  ic  Bhock,  67 
'  mi  shock  under  morphia, 
67 

17 


Local  anesthesia    in    abdominal  op- 
erations,  125 
in  brain  operations,  199 
in  cancer  of  the  uterus,  177 


McBurnet  incision,  1  18,  1  l'.' 
'.  Franklin,  156 

May...   139,  221 

clinic,  139 
Morbidity,  postoperative,  212 
Morphin  and  scopolamin,  113,   226, 
247 
in  abdominal  operal ions,  126 
in  bladder  operal  ions.  158 
in  exophthalmic  goiter,  192,  _'."in 
in  prostatectomy,  159 
effeel  on  kinetic  system,  67 
in  accidenl  cases,  205 
in  acute  appendicil is,  1  Is.  150 
protective  effect  of,  105,    1 13,    1 15, 
1 51 1 
Motor  mechanism,  activation  of,  208 
act  ivators  of,  22  I 
adaptation  for  discharge  of  en- 

30 
effeel  of  emotions  on,  96 
of  trauma  on,  under  inhalation 
anesthesia,  81 
organs  of,  31 
Moynihan,  119,  221 
gauze  pads,  177 
ringe,  1 19,  120,  139 
Mumford,  105 
Murphy,  I  17.  Jul 
method,  150 
rectal  drip,  ISO 


\  \i  -i  \.  :  live,  218 

Nephritis,  postoperath  e,  219 
Nervousness,  poet  opera  ti  c,  216 
la-oxid-oxj  gen,  1 16 
hock  under,  77 
of  trauma  under,  77 
in  alxiominal  operal  ions,  122   131 


258 


INDEX 


Nitrous-oxid-oxygen,  in  acute  abdom- 
inal infections,   147 
in  acute  appendicitis,  148 
in  amputations,  203 
in  brain  operations,  199 
in  cases  of  hypotension,  211 
in  exophthalmic  goiter,  192,  240 
in  two-stage  operations,  177 
plant  for  manufacturing,  252 
technique  of  administering,  226 
Novocain    as    a    protection    against 
postoperative  gas-pain,  214 
in  abdominal  operations,  126 
in  amputations,  203 
in  bladder  operations,  158 
in  common  duct  operations,  136 
in  gall-bladder  operations,  133 
in  herniotomy,  142 
in   operations   for   acute   appendi- 
citis, 148 
in    operations    for    cancer    of    the 

larynx,  181 
in    operations   for    cancer   of    the 

uterus,  177 
in     operations     for     exophthalmic 

goiter,  192 
in  rectal  operations,  144,  174 
in  removal  of  benign  tumors,  153 
in  resections  of  the  intestines,  140 
in  prostatectomy,  159 
in  stomach  operations,  138 
in  thyroidectomy,  196 
preparation  of,  118 
technique  of  administering,  117,  118 


Ochsner,  155 

cautery  irons,  178 

dietary,  150 
Osteotomy,  204 


Painful  scar,  postoperative,  214 
Pelvic  infections,  152 
Perineal  operations,  144 

Pneumonia,  postoperative,  220 


Postoperative  care  of  patients,  2-17 

hypert  hyroidism,  198 

gas-pains,  213 

morbidity,  212 

nervousness,  216 

painful  scar,  214 

pneumonia,  220 
Preoperative  care  of  patients,  246 
Prostatectomy,  dangers  of,  158 

technique  in,  159 
Pus  tubes,  operation  for,  156 


Quinin    and    urea   hydrochlorid,    ad- 
ministration of,  119,  120 
as     protection     against     gas- 
pains,  214 
in  abdominal  operations,  127 
in  accident  cases,  205 
in  amputations,  204,  205 
in  bladder  operations,  158 
in  gall-bladder  operations,  133 
in  herniotomy,  144 
in   operations   for   benign    tu- 
mors, 156 
in  operations  for  goiter,  192 
in  perineal  operations,  144 
in  rectal  operations,  145 
in  resection  of  the  intestines, 

140 
in'  stomach  operations,  139 
preparation  of,  120 


Rectal  operations,  144,  174 
Resection  of  the  intestines,  140 

end  results  in,  141 

ether  in,  140 

indications  for,  140 

technique  of,  141 
Rodman  operation,  175 
technique,  202 


Salpingitis,  156 

Schuchardt  hysterectomy,  176 


INDEX 


259 


Shock,  cause  of,  31,  32 
clinical  pathology  of,  80 
definition  of,  31,  100 
emotional,  histologic  changes  due 

to.   56 

essential  lesions  of,  31 

histologic  changes  due  to.  :;  I 

influence  of  inhalation  anesthesia 
upon,  77 

kinetic  theory  of,  29,  31,  34,  100 
evolution  of,  19 
foundation  for.  25 

organs  of  the  body  involved  in,  34, 
19 

prevention  of,  105,  107 

symbiotic,  7  1 

toxic,  foreign  proteid,  and  anaphy- 
lactic, histologic  changes  due  to, 
56 

traumatic,  histologic  changes  due 
to.  19,  50 

transfusion  of  blood  in.  106 

treatment  of,    105 

Spinal  anesthesia  in  abdominal  oper- 
ations, 125 
Stimuli,  adequate,  effect  of.  29,  31, 
'.II.  122 
enumeration  of.  32,  His 
mechanism  evolved  for  defense 

against,  93 
react  ions  to.  of  differenl  part  -  of 
the  body,  92 
Stomach,  cancer  of.  1 7 1 

opcral  ion-  on.    138 

acidosis  after.  139 
transfusion  of  blood  in.  138 
Strychnin,  effeel  on  kinetic  system, 
67,  lor, 


Suprarenal-,  histologic  changes,  cause 

of.  32,  34 
due  to  shock,  '■'<  1 
due  to  toxic,   foreign  proteid. 

and  anaphylactic  shock,  67 

due  to  traumatic  -hock.    1'.' 
effect  of  shock  under  morphia 
on,  ti7 
Suspension  of  the  uterus,  L57 


Teter,  117.  _'  15 

Thibault,  llo 

Thyroidectomy,  technique  of ,  L96 

Tongue,  cancer  of,    lsl 

Transfusion,  effeel  of  shock  after,  106 

in  hypotension  cases,  21 1 
Traumata,  effect  of  differenl  types  of, 
86 

susceptibility  of  different  parts  of 
the  body  to.  85 
Traumatic  shock,  histologic  changes 

due  to.  49,  50,  77 
Trendelenburg  position.  177.  239 
Trifacial  neuralgia,  200 
'rumor-,  benign,  L53 
Two-stage  operation-.  17:; 


I    I  ,i  I  R,  duodenal.    139 

gastric,  139 

(JterUS,  cancer  of,    17.") 

suspension  of,  17>7 


\\  \u\i  u.  \    i;  .  1 17.  252 
\\  orry,  effeel    of,    on    bodj    mecha- 
nism, 95 


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